British Journal of Anaesthesia 108 (S2): ii184–ii214 (2012)
doi:10.1093/bja/aer484
OBSTETRIC ANAESTHESIA
Paper No: 9.00
Desflurane vs. Sevoflurane for cesarean
section with 1 MAC. Neonatal effects
Nikolaos Noulas 1, Elisavet Karkala 1,
Dimitris Maliamanis 1, X. Anastasopoulos 2 and
N. Kampas 2
1 Apgar score at 1′ & 5′ between groups indicates that both inha-
Department of Anaesthesia. General Hospital Of Corinth-Corinth
Greece, 2 Obstetric Clinic, General Hospital of Corinth
Introduction: The obstetric population has a high incidence
of awareness and recall during general anaesthesia for cae-
sarean section. Desflurane, a volatile anesthetic agent with a
low blood/gas solubility, has been thoroughly studied but its
use (with 1 MAC) in obstetrics has not been adequately eval-
uated, the same occurs with Sevoflurane.
Objectives: This prospective study was undertaken to evalu-
ate the neonatal effects of Desflurane versus Sevoflurane in
elective cesarean delivery.
Methods: The study was performed from January 2010 to
July 2010. Eighty healthy parturients ASA I, aged 22-37 at
38-41 weeks of pregnancy, were randomly allocated in two
groups. The first group (group D) received 6% Desflurane
and the second group (group S) 2% Sevoflurane, plus 50:50
O2/air mixture. All patients were in the supine position with
a left tilt and preoxygenated. They all underwent a rapid se-
quence induction of anesthesia with Thiopental 5mg/Kg fol-
lowed by Succinylcholine 1mg/kg for tracheal intubation.
Anaesthesia was maintained immediately with a concentra-
tion of Desflurane 1 MAC (group D) and Sevoflurane 1 MAC
(group S) with 50% O2 and 50% air. Induction delivery
time (ID-time) was defined from induction of anaesthesia
to umbilical cord clamping. Neonatal outcome was evaluated
by vital signs, acid – base status, PO2, PCO2 at birth (blood
from umbilical vein), and after 60 min from heel capillary
blood, and Apgar score at 1′ and 5′ min. The patients were
interviewed about intraoperative awareness 24 and 48 h
after operation. Finally we measured the intraoperative satis-
faction of surgeons and parturients. Statistical analysis was
performed with SPSS software version 17.
Results: Patients in both groups developed transient hyper-
tension and tachycardia during induction of anaesthesia
(plus 20-24% from baseline) which returned to baseline
values in approximately 5 min. Maternal blood loss did not
differ significantly between the two groups and none of the
patients developed intraoperative awareness (p¼0,14,
p¼0,23). Mean ID-time was equal between groups
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(3,23+0,14 min group D vs. 3,51+0,32 min group S). Neo-
natal outcome was good in both groups. Mean values of
PH, PO2 and PCO2 did not differ significantly between
groups. More neonates (36/40) in the Desflurane group had
transient increased cardiac pulses (up to 130 bits) versus
the Sevoflurane group (12/40) (P,0.05). Satisfaction of sur-
geons and parturients was equal between groups.
Conclusions: The similarity of Acid-base variables, PO2, PCO2,
lational anaesthetic agents are safe for mother and newborn
when administered at 1 MAC in elective cesareans sections.
Paper No: 97.00
Observational study to assess
postoperative pain management strategy
in elective caesarean section patients
Samina Ismail, Khurrum Shahzad and
Faraz Shafiq
Background: With the dramatic rise in the rate of caesarean
deliveries in the last two decades (1-3), postoperative pain
management of these patients has become a major
medical and nursing challenge. Pain should be properly
assessed and addressed in the postoperative period (4).
Objective: The aim of our study was to observe the pain
management strategy used in our hospital for elective cae-
sarean section patients. In our observations, we reviewed
broad areas of outcome, such as effectiveness, safety and
tolerability. Effectiveness was inferred from visual pain
scores and satisfaction. Safety and tolerability was assessed
by the occurrence of side effects.
Material and method: We reviewed all patients who under-
went elective caesarean section from December 2008- May
2009. On the day of surgery data collected included patient’s
demographics, type of intra-operative anaesthesia and anal-
gesia, postoperative pain orders. On the 1st postoperative
day, anaesthesia team determined verbal pain score(VAS),
any complications and patient satisfaction with pain man-
agement strategy.
Results: Total 263 patients were reviewed. Postoperative anal-
gesia regime was started by obstetric team in 81% of patients
and in 19% by anaesthesia team. The most common modality
of pain management was intravenous opioid infusion (94%)of
pethidine,tramadoland morphine with co-analgesia (99%) in
the form of NSAIDs. The analysis of pain by verbal pain
Abstracts presented at WCA 2012
scoring showed mild pain in 89% of patients, moderate pain in
9% of patients and severe pain in 0.8% of patients during
resting stage. The Dynamic pain score was mild in 60%, mod-
erate in 33% and severe in 6.8% of patients. Opinion regarding
their pain management was satisfactory in 91.6% of patients,
while 8.4% of patients were not satisfied with their pain man-
agement. Overall 9% of patients (n¼24) complained of differ-
ent complications. None of the complications were severe and
responded to treatments.
Discussion: Although the postoperative pain management
was adequate in terms of patients’ safety, it was not effective
according to the goal set by Joint Commission on Accredit-
ation (5) of uniformly low pain score of no more than 3 out
of 10 both at rest and with movement.
Conclusion: In order to reach the international proposed
standard, we need to expand the coverage of acute pain
service to develop a nurse based, anaesthesiologist super-
vised pain service for caesarean section patient. This
service would assess and treat pain to a degree that facili-
tates function and quality of life.
References
1 Villar J, Valladares E, Wojdyla D, Zavaleta N, Carroli G, Velazco A
et al. Caesarean delivery rates and pregnancy outcomes: the
2005 WHO global survey on maternal and perinatal health in
Latin America. Lancet 2006; 367: 1819– 1829 (Pub Med).
2 Churchill H, Savage W, Francome C. Caesarean birth in Britain.
London: Middlesex University Press 2006.
3 MacDorman MF, Declercq E, Menacker F, Malloy MH. Infant and
neonatal mortality for primary cesarean and vaginal births to
women with “no indicated risk”, United States, 1998-2001 birth
cohorts. Birth 2006; 33: 175– 182 (Pub Med).
4 Rawal N. 10 years of acute pain services: achievements and chal-
lenges. Reg Anesth Pain Med 1999; 24: 68–73.
5 Pan PH. Post caesarean delivery pain management: multimodal
approach. Int J Obstet Anesth 2006; 15: 185– 188.
Paper No: 98.00
Postoperative analgesia for caesarean
section: comparison of patient controlled
analgesia with continuous infusion using
pethidine
Samina Ismail, Gauhar Afshan, Abdul Monem and
Aliya Ahmed
Introduction: Management of postoperative pain after cae-
sarean section (C/S) requires a balance between pain relief
& undesirable side effects of drugs and technique. Various
studies (1,2) using continuous opioid infusion could not iden-
tify ideal dose to provide adequate analgesia without supple-
mental bolus doses or side effects to maintain an adequate
level of analgesia during rest and activity (3). PCA devices are
now widely used in clinical practice, and are among the most
recommended techniques for the control of moderate to
BJA
severe postoperative pain (4). We hypothesized that PCA
could result in lower pain scores, less side effects, more
patient satisfaction and reduction in breakthrough pain re-
quiring rescue analgesia.
Objectives: In order to improve conventional postoperative
pain management after caesarean section, which in our hos-
pital setting is continuous narcotic infusion, we compared it
with patient controlled analgesia (PCA).
Method: 120 patients after written informed consent were
enrolled in the study after an uneventful elective caesarean
section under spinal anaesthesia. All patients at 120
minutes after institution of spinal anaesthesia received
0.5mg/kg bolus of pethidine. Depending upon the random-
ization by sealed envelope method, group P received PCIA
with 0.15mg/kg bolus pethidine with 10-minute lockout &
group C received continuous pethidine infusion at a rate of
0.15mg/kg /hr. All patients received tablet paracetomal 1
gram three times a day and diclofenac suppository 100mg
twice a day during the study period.
Results: The verbal pain score, need for rescue analgesia, in-
cidence of nausea and vomiting was significantly lower (p
value ,0.001) in PCA group as compared to continuous infu-
sion group at 6, 12 and 24hrs in the postoperative period.
Ninety eight percent of the patients were satisfied with
pain management and wanted the same form of analgesia
for future surgeries in the PCA group as compared to 70%
(p ,0.001) in Group C.
Discussion: PCA enables patient’s participant in pain relief and
usually results in improved analgesia (4). However these
devices are expensive and material costs per patients are
usually higher compared with conventional analgesia (5). In
our study we observed better pain control, less need for
rescue analgesia for breakthrough pain, less incidence of
nausea and vomiting and greater patient satisfaction.
Conclusion: Since in our part of the world we do not have pre-
servative free narcotic to use by intrathecal route, we as care
giver can improve postoperative pain management by using
PCA instead of continuous narcotic infusion in patients
undergoing caesarean section.
References
1 Bonnet MP, Mignon A, Mazoit JX. Analgesic efficacy and adverse
effects of epidural morphine compared to paranteral opioids
after elective caesarean section: A systemic review. European
Journal of Pain 2010; 1: 894– 99.
2 Church JJ, Continuous narcotic infusions for relief of postoperative
pain. British Medical Journal 1979; 1: 977– 9.
3 Stapleton JV, Austin KL, Mather LE. A pharmacokinetic approach to
postoperative pain: Continuous infusion of pethidine. Anaesthesia
& Intensive Care 1979; 7: 25 –32.
4 Practice guidelines for acute pain management in the periopera-
tive setting. A report by the American Society of Anesthesiologists
Task Force on Pain Management, Acute Pain Section. Anesthesi-
ology 1995; 82: 1071– 1081.
5 Unlugenic H, Vardar MA, Tetiker S. A comparative study of the An-
algesic effect of patient controlled morphine, pethidine and tra-
madol for postoperative pain management after abdominal
hysterectomy. Anesthesia & Analgesia 2008; 1: 309– 12.
ii185
BJA
Paper No: 99.00
Technique of anaesthesia for different
grades of caesarean section: a cross
sectional study
Samina Ismail, Faraz Shafiq and Aliya Malik
Introduction: Regional anaesthesia (RA) for caesarean
section (CS) is the preferred option when balancing risks
and benefits to the mother and her foetus. The Royal
College of Anaesthetists audit guidelines suggest that 85%
of emergency CS should be conducted under RA and the con-
version to general anaesthesia (GA) should be less than 3 %
for emergency, and less than 1% for elective surgery (1).
Objective: The percentage use of regional anaesthesia (RA)
and failure rate of RA for different grades of caesarean
section (CS) has become a marker of quality for obstetric an-
aesthesia service(2). The objective of our prospective observa-
tional study is to find out the technique of anaesthesia used in
different grades of CS, reasons for choosing general anaesthe-
sia (GA) and failure rate of RA in our hospital setting.
Methods: This prospective cross sectional study was carried
in the obstetric unit of Aga Khan University Hospital from
1st January 2010 to 31st May 2011. The anaesthetist per-
forming the procedure filled out the data collection pro-
forma. Suggested Indicators were percentages of Grade 1-4
CS done under RA and GA, % of failed regional, % of failed re-
gional in different grades of CS.
Results: Total of 407 patients having CS was reviewed for five
months of study period. The technique chosen was GA in
49% (n¼201) and RA in 51 % (n¼206) of patients. There
was no significant difference between the use of GA and
RA for grade 2-4 CS with a slight increase margin of differ-
ence for grade1 CS (63% GA vs 37% RA). Another finding
was a high rate (44%) of elective CS done under GA.
Patient preference (45%) was the most common reason for
choosing GA. Fourteen patients (6.7%) required conversion
from regional technique to GA; eleven patients had grade
1-3 CS and three patients had grade 4 CS.
Discussion: Our rate of regional technique for CS ranges from
37 % -49% for grade 1-3 CS and 45% for elective Grade 4 CS,
which is very low compared to the recommended inter-
national standard (1).
Conclusion: In order to meet the international standards for
best practice, guidelines should be made in consultation with
the obstetrician and nursing staff regarding use RA for differ-
ent grades CS. Patient education regarding the use and ben-
efits of RA needs to enforced.
References
1 Royal College of Anaesthetist. Technique of anaesthesia for Cae-
sarean section. In: raising the Standard: a Compendium of Audit
Recipes. http://www.rcoa.ac.uk/index.asp. page ID¼125. Accessed
16/01/2011.
ii186
Abstracts presented at WCA 2012
2 Thomas J, Paranjothy S. Royal College of Obstetricians and Gynae-
cologists. Clinical Effectiveness Support Unit. The National Sentinel
Caesarean Section Audit Report. London: Royal College of Obstetri-
cians and Gynaecologists Press, 2001.
Paper No: 124.00
Neonatal effects of bolus administration
of ephedrine and phenylephrine during
neuraxial anesthesia for emergency
caesarean section: a retrospective study
Hiromi Kurokawa, Miwako Nakao and
Katsunori Ueda
Hiroshima Prefectural Hospital
Introduction: Both ephedrine and phenylephrine are used as
the pressor agent in caesarean section (CS) under neuraxial
anesthesia. Ephedrine might be worse for neonatal acid-base
balance. However, most of the researches have been investi-
gated in elective CS and little is known in the emergency
situation.
Objectives: The aim of this study is to investigate the effects
of ephedrine and phenylephrine on the neonatal conditions
during the emergency CS under neuraxial anesthesia.
Methods: We retrospectively studied the emergency cesar-
ean deliveries under neuraxial anesthesia in the period
from Jan 2009 to May 2011. Umbilical arterial pH, base
excess, and Apgar score at 1 and 5 min were compared
between the cases given ephedrine (group E) and phenyleph-
rine (group P).
Results: There have been 277 emergency CS in this period. Of
these we have 229 babies with the records. 111 babies (48%)
were from the mother received no vasopressors, 7 babies
(3%) were from those received both ephedrine and phenyl-
ephrine, 61 babies (27%) in group E, and 50 babies (22%)
in group P. The mean dose of ephedrine used was 9.4+-
5.4 mg and of phenylephrine was 155.0+- 74.4 microg.
Median umbilical arterial pH and base excess were 7.33
and -2.5 for group E, and 7.32 and -3.3 for group
P. (P¼0.11, P¼0.33, respectively: group E versus group P)
Apgar scores at 1 and 5min were 9 and 10 for all groups.
(P¼0.62, P¼0.82, respectively: group E versus group P)
Conclusions: Umbilical arterial pH and base excess were
similar between the study groups. Clinical neonatal
outcome was also similar. Thus in emergency cesarean
delivery, ephedrine and phenylephrine are both suitable,
which is different from the situations of elective cesarean de-
livery and is consistent with other studies of high risk one. It
is partly because ephedrine usage in our cases is relatively
smaller than those of previous studies of low-risk caesarean
delivery.
Abstracts presented at WCA 2012
Paper No: 166.00
Prevention of hypotension during cesarean
section under spinal anesthesia:
incremental administration of 0.2%
bupivacaine
Yoshimichi Namba
Okinawa Kyodo Hospital, Naha, Japan
Introduction & Objectives: Patients undergoing spinal anes-
thesia for cesarean section are at greater risk of supine
hypotension than those not undergoing-cesarean section.
In addition to aortocaval compression and the extent of
sympathetic blockade produced by spinal anesthesia, the
total amount of local anesthetic used may play a role in
determining the magnitude of arterial hypotension. In
this study, incidence and magnitude of hypotension
during cesarean section under spinal anesthesia was deter-
mined by using incremental doses of 0.2% bupivacaine, to-
taling 6 mg.
Methods: Hyperbaric bupivacaine 0.5% solution (4 ml,
20 mg) was diluted with normal saline (6 ml) to produce
0.2%. Forty-three non-hypertensive patients undergoing ce-
sarean section were studied. A combined spinal/epidural
needle was inserted at the L3-L4 interspace with the
patient lying on her right side. Bupivacaine solution (1 ml,
2 mg) was injected incrementally at intervals of 2 minutes
to a total of 3 ml (6 mg). A blood pressure decrease of
greater than 20% in baseline pressure or below 90 mmHg
was treated with phenylephrine.
Results: The anesthetic level at proceeding to surgery was
T5-T3. Only 3 of the 43 patients needed vasopressor
treatment.
Conclusions: Despite left uterine displacement and intra-
vascular volume expansion, as many as 50% of patients
will still manifest significant hypotension. The reported
dose of bupivacaine of spinal anesthesia for cesarean
section is typically 12 to 15 mg. Although increasing the
dose of spinal anesthetic increases block height, doses
above 15 mg significantly increase the risk of complica-
tions.(1) This study shows that when 0.2% bupivacaine is
given in incremental doses, 1 ml (2 mg) by 1 ml (2 mg), a
total of 6 mg is sufficient to produce satisfactory anesthe-
sia for cesarean section. This lower dose minimizes the in-
cidence and magnitude of spinal anesthesia for cesarean
section (only 3/43¼7%). Prolonged surgery and post-
operative pain can be controlled by the combined spinal/
epidural anesthesia.
References
1 Birnbach DJ, Browne IM, Anesthesia for Obstetrics, Chap. 69.
Miller’s Anesthesia, 7th Edition. Edited by Miller RD, Churchill Living-
stone, 2010, 2203– 2240.
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Paper No: 181.00
Maternal and neonatal outcome following
caesarean section under spinal versus
general anesthesia in kenyatta national
hospital maternity theatre
Rosemary Mukunzi
Introduction: The risk of maternal death with caesarean
section is four times that associated with all types of
vaginal Birth. Poor maternal and neonatal outcome are
more commonly associated with general anesthesia for c/s
as compared to spinal anesthesia. This study compared the
safety and the effectiveness of the two techniques for mater-
nal and neonatal outcome for all the indications for caesar-
ean section.
Objective: To determine the preferred technique of anesthe-
sia in relation to the indications for caesarean section. To
compare the effects of spinal anesthesia with those of
general anesthesia on the maternal outcome of caesarean
section. To compare the neonatal outcome with the effects
of spinal anesthesia and general anesthesia. To determine,
what type of anesthesia is more efficacious in order to min-
imize maternal and neonatal morbidity and mortality rates
Methodology: A Prospective Observational Descriptive study
carried out in KNH maternity theater. A total of 196 patients
were recruited in this study and they all completed the study.
Results In this study, of 196 patients, 43.9% c/s were per-
formed under GA. The rest were under SA regardless of the
indication for the c/s (p¼0.032). From the data, SA was per-
formed in 40.8%, whilst GA 59.2% in a group of patients with
immediate indications for c/s. For patients who had urgent
indications for c/s, SA was performed in 60.8% out of 102
cases.. Out of 35 elective cases, 24 cases were performed
under SA and 11 cases under GA. Intra-operatively the com-
monest maternal side effect observed in the two groups was:
Hypotension in the SA group (p,0.001). Hypotension in the
SA group was 52cases (47.3%) and in the GA group,
12cases(14%). Neonatal outcome as per the stratified indica-
tions for c/s: There was higher neonatal Apgar score in the SA
group. Significantly neonatal admissions to NBU in the time
defined were associated with GA; there were 22 admissions
of which 77.3% were due to respiratory distress. In SA 8
admissions were observed and respiratory distress accounted
for 6 neonates out of 8 admissions. From this data analysis, it
was observed that GA was highly associated with poor neo-
natal Apgar score and morbidity as compared to SA.
Discussion: In this prospective descriptive, observational
study; there was a fairly equal age distribution of patients
in the two groups of anesthetic technique used. The mean
age for both techniques was 28.09 years with a standard de-
viation of 5.4. Age did not correlate with the type of anesthe-
sia for C/S. In the study, Our finding is in agreement with
other studies that; hypotension is the most common
adverse event when spinal anesthesia is used for caesarean
ii187
BJA
section. In our study, it¡s the absolute systolic pressure that
was defined. We considered the lowest recordings in systolic
BP of ¡Ü 90mmHg intra-operatively. Comparative studies
have been done comparing the neonatal outcome for the
two anesthetic techniques and our findings are in agreement
with other international findings.
Conclusions: Spinal anesthesia and General anesthesia are
both effective for c/s, but with significant differences in ma-
ternal and neonatal outcome.
References
1 Enkin M, Keirse MJNC, Nellson JM, Crowther C, Duley L, Hodnett E
et al. “Aguide to effective care in pregnancy and child birth.3rd
eddition.” New York: Oxford University press, 2000.
2 Andersen HF, Auster GH, Marx GF, MerkatzI R. “Neonatal stutus in
relation to incision interval, obstetric factors and anesthesia at
ceasarean delivery.” American journal of Perinatology, 1987; 4:
279–83.
3 Hocking G, Wildsmith JAW. “Intrathecal drug spread.” British
journal of anesthesia, 2004; 93: 568 –78.
4 Lagan G, McLure HA. “Review of local anaesthetic agents.” Current
Anesthesia & Critical Care, (2004) 15: 247– 254.
Paper No: 192.00
Routine use of Remifentanil-PCA in labour
in Switzerland combined with web based
continuous quality control
Andrea Anna Melber, Daniel Reinhardt and
Alexsandra Bansi
Institute of Anaesesiologie and Intensive Care, Salem Hospital,
Berne, Switzerland
Introduction: Due to its profile of action the strong opioid
Remifentanil qualifies as an ideal analgesic drug during
labour. Applied as patient controlled analgesia (PCA) this
method offers optimal safety and comfort for the parturient
and child. Although frequently used in other countries, its
routine use has only been established in a few hospitals in
Switzerland yet.
Objectives: Our objectives were to establish and spread a
standardized routine use of Remifentanil-PCA in labour in
swiss hospitals. This includes a web based data collection
of every application in order to ensure safety and quality
control right from the beginning.
Methods: Initiated from Salem Hospital in Berne, a website
was created to implement this method in Switzerland. The
website contains a concise direction for professionals and a
questionnaire, collecting a database for each application.
This database comprises the course, the complications for
mother and child as well as the satisfaction of all parties.
In order to provide high safety we used fixed boli of 20
mcg and continuous pulse oxymetry. No additional analgesia
were used.
ii188
Abstracts presented at WCA 2012
Results: After implementation of the method for routine use
in labour in 2008 more than 1000 women (.40% of all births
in our hospital) delivered with the support of a
Remifentanil-PCA. Five other hospitals started to participate
in our data recording system. The safety for mother and
child as well as the satisfaction of all parties were excellent.
95% of parturients and midwifes would choose this method
again or recommend it for child birth.
Conclusion: Despite reassuring results large numbers are
often needed to detect rare complications or side effects.
With the registration of every application of all participating
hospitals via this website (www.remipca.org) the datapool
grows continuously in a short time. This allows constant ad-
justment of the procedure as well a quick feedback in case of
adverse effects. The routine use of Remifentanil-PCA in
labour is a safe method with excellent acceptance of parturi-
ents, midwifes, obstetricians and anaesthetists. With the
help of the webbased data collection we offer a nationwide
launch and regular audits which provides excellent quality
management and safety especially valuable for hospitals
with small obstetric departments.
References
1 Blair JM, Hill DA, Fee JPH. Patient-controlled analgesia for labour: a
dose finding study. Br J Anaesth 2001; 87: 415– 20.
2 Gupta N, Hill D, Wallace N. Impact of introduction of Remifentanil
PCA for labour analgesia on epidural rate and obstetric outcome
over a two-year period. Int J Obstet Anesth 2008; 17:S51.
3 Harbers J, Drogtrop H, Ieperen R. Remifentanil is safe and effective
for patient controlled intravenous analgesia during labour: the
results in 305 parturients. Int J Obstet Anesth 2008; 17:S52.
Paper No: 200.00
Anaesthesia for caesarean section in
morbidly obese parturients – a seven year
retrospective audit
Mukesh Shah, Sandeep Kulkarni and
Zanariah Yahaya
Kandang Kerbau Hospital, Singapore
Introduction: Morbidly obese parturients at the time of cae-
sarean section, defined as those with a pre-delivery BMI of
more than 45 kg.m-2, are believed to have a greater anaes-
thetic risk and associated with greater anaesthetic difficulties
and problems.
Objectives: To determine anaesthetic choices and doses
used in elective and emergency caesarean section, anaes-
thetic difficulties and problems during anaesthesia establish-
ment and surgery, and anaesthetic and surgical
complications over this seven year period.
Methods: A retrospective audit of anaesthesia for this group
was done for seven years from June 2004 to May 2011, since
the time we began data collection.
Abstracts presented at WCA 2012
Results: A total of 54 anaesthetics in 48 parturients were given
in this period. The majority were in Malay parturients (37,
68.5%), followed by Indian (10, 18.5%) and Chinese (7,
13.0%). Median weight was 118.0 kg, median BMI 48.26,
median gravidity 3, median gestation 38.0 weeks, and mean
age was 31.2 years. Antenatal medical and obstetric problems
were present in 13 (24.1%) and 19 parturients (35.2%) respect-
ively. The median number of previous caesarean sections was
1. 26 (48.1%) anaesthetics were given for elective surgery. The
most common indication was previous caesarean section in 26
(48.1%) anaesthetics. Regional anaesthesia comprised 48
(88.9%) anaesthetics, of which 28 (51.9%) were single shot
spinal anaesthesia. The regional anaesthetic procedure was
successful in all despite requiring more than one attempt
37.5% of the time. Success of regional anaesthesia induction
and success for surgery was 95.9% and 89.5% respectively.
General anaesthesia conversion was required only thrice
(5.6%). There was complicated regional anaesthetic place-
ment in 11 (20.3%) anaesthetics. Doses for spinal, combined
spinal-epidural and epidural top-up anaesthesia and block
height obtained were similar to non-obese parturients. Epi-
dural space from skin and length of epidural catheter left
in-situ for epidural anaesthesia ranged from 6.0 to 9.0 cm
and 3.5 to 6.0 cm respectively. General anaesthesia was un-
eventful in those that had general anaesthesia and general
anaesthesia conversion. Only one parturient had backache fol-
lowing anaesthesia. Mean duration of surgery was 51.6
minutes and surgical complications were present in 7
(12.9%) parturients and both these were not related to senior-
ity of the main surgeon. 7 (12.9%) parturients had longer hos-
pital stay of 4-6 days. Neonatal complications unrelated to
surgery were present in only two cases.
Conclusions: The majority are performed successfully under
regional anaesthesia. Doses used are similar to non-obese par-
turients. Anaesthetic and surgical problems are also minimal.
Paper No: 217.00
Ultrasound guided Transverses Abdominis
Plane block – An underused option for
postoperative analgesia after caesarean
section.
Om Prakash, VArun, Punit Mehta, Deep Arora and
Shibani Das
Max Superspecialty Hospital, New Delhi, India
Introduction: Post operative pain is a major factor limiting mo-
bilization and interferes with breast feeding and maternal
infant bonding in patient who had caesarean section.
Advances in ultrasound guided nerve blocks makes it possible
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to provide better quality of analgesia with fewer adverse
effects.
Objectives: We hypothesized that if TAP blocks were effective
then requirements of systemic analgesics would be signifi-
cantly less in these patients with reduction in pain scores.
Methods: 40 patients undergoing Caesarean section with
Pfannensteil incision under spinal anesthesia belonging to
ASA I & II categories were randomized in two groups of 20
each after written informed consent. First group received
ultrasound guided TAP block at the end of the procedure
with 20ml 0.25% Bupivacaine on each side and the second
group was kept as control. Both groups postoperatively
received PCA Fentanyl at the rate of 0.3mcg/kg with lockout
interval of 15min. All patients also received Inj. Diclofenac
75mg twice daily and Inj. Paracetamol 1gm thrice daily.
PCA Fentanyl was continued 24hrs postoperatively and the
patients were assessed at intervals of 4hrs for the next
24hrs. Patients were encouraged to use the PCA to keep
their VAS scores less than 4. We looked at the analgesic re-
quirement of both these groups, pain scores and adverse
events. Fentanyl requirement was analysed in both the
groups using Wilcoxon rank sum test.
Results: No significant difference was found in either group in
terms of ASA status, age and weight. Fentanyl requirement
and VAS score were analysed over five different at
T1(0-4Hrs), T2(4-8hrs), T3(8-12hrs), T4(12-24hrs), T5(Total in
24 hrs).
Control Group TAP Group p Value T1 150+74.27 22.75+18.95
,0.0001 T2 131.25+44.86 32.5+20.55 ,0.0001 T3
96.5+35.51 34.5+22.35 ,0.0001 T4 169.75+69.71
54.75+45.98 ,0.0001 T5 515.5+196.22 145.5+80.83
,0.0001 (Fentanyl dose in mcg – mean+SD) Average VAS
scores for the patients in the control group was 2.1 and for
those in the TAP group was 1.1. No complication were
observed.
Discussion: TAP block as a part of multimodal pain manage-
ment improves post operative analgesia in the first
24hrs(1,2) after caesarean section and this is essential for
early ambulation, infant care and preventing postoperative
morbidity(2). TAP block can be performed relatively easily
and precisely using ultrasound as it allows observation of
the needle passage through the tissues and allows us to visu-
alize the spread of the injectate in the neurovascular
plane(3). It also reduces the theoretical complications of a
blind TAP block namely peritoneal and bowel perforation.
In our patients who received USG guided TAP block the
requirements of Fentanyl at each point of time was signifi-
cantly less than the group which did not receive TAP block.
These patients also had lower VAS score but the sample
size was inadequate to establish significance.
Conclusions: USG guided TAP block is safe and an effective
component of multimodal postoperative analgesia in
patients undergoing Caesarean section. It significantly
reduces the opioid requirement but larger studies are
ii189
BJA
required to show the reduction of opioid related side effects
and reduction in VAS score.
References
1 McDonnell John G et al. The Analgesic Efficacy of Transversus Ab-
dominis Plane Block After Cesarean Delivery: A Randomized Con-
trolled Trial, Anesthesia & Analgesia 2008; 106: 186– 191
2 Ola P Rosaeg et al. Peroperative multimodal pain therapy for Cae-
sarean Section: Analgesia & fitness for discharge. Can journ of An-
aesthesia 1997; 44:8; 803– 809
3 Farragher RA, Laffey JG. Postoperative pain management following
cesarean section. In: Shorten G, Carr D, Harmon D, et al.,eds. Post-
operative pain management: an evidence-based guide to practice.
1st) ed. Philadelphia, PA: Saunders Elsevier, 2006:225– 38
Paper No: 304.00
Study of postoperative analgesia after the
cervical cerclage
Nozomu Nishikawa 1, Risa Katsuyama 2,
Tetsuya Nomura 3, Hiroyuki Yamaguchi 4 and
Hiroyuki Furukawa 5
1
Chief Anesthesiologisit, 2 Dept of Anesthesiology, 3 Director of
Hospital, Chief Gynecologist, 4 Dept of Gynecology and Obstetrics,
5
Dept of Gynecology and Obstetrics
Introduction: Cervical cerclage might be undergone for the
cervical incompetence in pregnant women. Pain subsides
within about 24 hours after surgery. However, abdominal
pain and/or surgical pain may also strengthen the tension
of uterus. With that in mind, suppression of the postoperative
pain is reasonable procedure for these women. We compared
the intensity of postoperative pain among three types of an-
esthesia methods.
Method: Anesthesia was performed following three
ways. 1. Spinal anesthesia with local anesthetic. 2. Spinal an-
esthesia added morphine. 3. Combined spinal epidural anes-
thesia (CSE) followed by patient controlled epidural
anesthesia (PCEA) with 0.1% ropivacaine. Postoperative
pain intensity was inferred from consumption of analgesics
and from the medical records. Side effects, especially
nausea and vomiting were also examined.
Results: Between Jan 2009 and Jul 2011, forty-four pregnant
women underwent for cervical cerclage. We examined these
cases retrospectively on the medical records. Spinal anesthe-
sia was performed for 15 pregnant women. One had no pain
at all after the surgery. Three had severe pain and five had
moderate pain. Six felt nausea and two women vomited
once and several times. Six women were performed
surgery under the spinal anesthesia added with small
amount of morphine (0.2mg). All were not used additional
analgesics after the surgery. But four women vomited
several times and another one woman felt nausea for
more than ten hours. CSE anesthesia was performed for 23
women. Eight women did not feel any pain after the
ii190
Abstracts presented at WCA 2012
surgery. Nine felt light pain, but were well controlled with
using PCEA. Four felt severe pain and used other analgesics
twice or more times. Two felt nausea but any person did
not vomit.
Conclusion: In Japan, cervical cerclage were mainly per-
formed under the spinal anesthesia. But many women felt
severe post operative pain after spinal anesthesia. Addition
of morphine to the spinal anesthesia was one of resolution
for postoperative pain, but many were suffered from severe
nausea and vomiting. Combined spinal epidural anesthesia
is complicated procedure when compared with spinal anes-
thesia. However, considering the postoperative pain, patients
who underwent the surgery under CSE may suffer less pain.
In addition these patients often felt less nausea and vomit-
ing. We concluded that CSE anesthesia followed by PCEA
was the most comfortable method of postoperative anal-
gesia for pregnant woman who had undergone cervical
cerclage.
Paper No: 332.00
Effect of Intrathecal Midazolam in the
Severity of Pain in Cesarean Section: A
Randomized Controlled Trial
Ali Karbasfrushan, Mojtaba Niazi, Naser Hemati,
Abdolhamid Zokaei, M. Moradi and
Alireza Ahmadi
Department of Anesthesiology, Critical Care and Pain
Management, Kermanshah University of Medical Sciences, Iran
Introduction: The benzodiazepines are used primarily for
anxiolysis, amnesia and sedation. However, recent investiga-
tions have shown that some forms of this group of drugs
have also direct effect on pain.
Objectives: This study aims to determine the effect of Mida-
zolam in reducing the severity of pain in women scheduled
for elective cesarean section.
Methods: This was a prospective, randomized double blind,
two group parallel study, conducted in Imam Reza hospital,
an affiliate of Kermanshah University of Medical Sciences.
Parturient women who met study inclusion criteria were con-
secutively assigned into either experimental (n¼62) or
control groups (n¼62). Women in the experimental group
received Bupivacaine (10 mg) plus Intrathecal Midazolam
(2 mg) (BM) and those in the control group received Bupiva-
caine plus Normal saline (BNS). The study main outcome
pain severity was measured by Verbal Numerical Rating
Scale. The study protocol was approved by the ethic commit-
tee of Kermanshah University of Medical Sciences and
patients signed consent forms. The preservative-free midazo-
lam was approved for spinal use.
Results: In compare with the BNS group, mothers in the BM
group reported significantly better relief in pain 15-min
(p¼0.006) and 120-min (p¼0.007) after the surgery. There
Abstracts presented at WCA 2012
were no statistically significant differences between the
groups in regard to the intensity of pain 5, 30, 60, 240 min
after the surgery. The average time until the first dose of
additional analgesic, per mother’s request, was 142/
18+55/19 min in the BM vs. 178/06+77/33 min in the BNS
group (p ¼,0.021).
Conclusion: Combination of Bupivacaine plus Intrathecal
Midazolam was an effective anesthetic technique to
provide improvement in pain. The onset of sedation was
faster in the BM group compared with the BNS group. The
duration of effective analgesia, and the time for regression
of sensory analgesia was the same in both groups in our
study. However, incidence of nausea and vomiting was
higher in the experimental group.
Paper No: 342.00
Tranexamic acid reduces blood loss in
post-partum haemorrhage by reducing
hyperfibrinolysis
Anne-Sophie Ducloy-Bouthors 1, Alain Duhamel 2,
Francoise Broisin 3, Hawa Keita 4 and
Sylvie Fontaine 5
1
CHU Lille, Pole d’Anesthésie-Réanimation, Pole d’obstétrique,
Pole de Santé Publique, and Pole d’Hématologie Transfusion,
F-59000, 2 Universite Lille Nord de France, EA2694 and EA2693,
3
de la Croix Rousse, Hôpitaux civils de Lyon, Pole, 4 Universite Paris
7 - Diderot, Service, 5 Maternité Monaco, Service
d’Anesthésie-Réanimation
Background: Post-partum haemorrhage (PPH) is a leading
cause of maternal death. Given the beneficial effects of tran-
examic acid (TXA) in elective surgery and bleeding trauma,
we hypothesized that TXA can reduce blood loss in PPH.
Methods: In this French randomized controlled trial, women
with PPH.800mL following vaginal delivery were assigned to
receive TXA (loading dose 4 g/1 hour, then infusion of 1g/
hour over 6 hours), or not. At 4 time-points (T1¼inclusion,
T2¼T1+30 min and T3¼T1+2 hours, T4¼T1+6 hours), the
volume of blood loss, and the use of packed red blood cells
(PRBC) and of colloids were recorded. Procoagulant treat-
ments (fresh frozen plasma, platelets, fibrinogen) or invasive
procedures could be used after T3, or at any time in case of
intractable bleeding. Primary objective was to assess the ef-
ficacy of TXA in the reduction of blood loss. Secondary objec-
tives were the effects of TXA on 1)bleeding duration,
2)anaemia, 3)transfusion requirement, 4)need for invasive
procedures and 5)biological data.
Results: 144 women (72 TXA and 72 controls) fully com-
pleted the protocol. Blood loss between T1 and T4 was
lower in the TXA group (median 173 [1st-3rd quartiles
59-377]mL) than in controls (221[105-564]mL, p¼0.040). In
the TXA group, bleeding duration was shorter, and progres-
sion to severe PPH and PRBC transfusion were less frequent
than in controls (p,0.03). Invasive procedures were
BJA
performed in 4 women in the TXA group and in 7 controls
(p¼NS). PPH stopped after only uterotonics and PRBC in
93% of women in the TXA group vs 79% of controls
(p¼0.016). Mild transient adverse manifestations (vomiting,
blurred vision) occurred more often in the TXA group
(p¼0.002). The major biological effect was the drastic reduc-
tion of D Dimers in TXA group (p¼0,002).
Conclusion: This study brings the first demonstration that
TXA reduces blood loss and maternal morbidity in PPH.
Adverse effects were mild and transient. A larger study
should be performed to investigate whether TXA could
reduce maternal morbidity worldwide.
Paper No: 343.00
ROTEM in obstetric: Near patient-test as
predictor of post-partum hemorrhage
Anne-Sophie Ducloy-Bouthors, Anne Bauters,
Antoine Tournoys, Benedicte Wibaut and
Pierre Richart
CHU Lille, Pole d¡fAnesthésie-Réanimation, Pole d¡fobstétrique,
Pole de Santé Publique, and Pole
Post partum hemorrhage (PPH) remains a major cause of
maternal morbidity and mortality related to childbirth;
Charbit and al (1) have shown decrease of fibrinogen to be
an early predictor of the severity of PPH. We hypothesized
that ROTEM¥ (pentapharm, Germany), a near-patient test
of perioperative hemostasis, could detect hemostatic altera-
tions in the early stage of PPH.
Patients and methods: PPH was defined as uterine
bleeding.800 ml occuring at delivery, persisting after
manual exploration of uterine cavity. No coagulant treat-
ment was administered during the first two hours. A15
FIBTEM (FIBTEM amplitude at 15 min) and fibrinogen level
(Clauss) were measured in 23 PPH women at the time of
PPH diagnosis (T1) and two hours later (T2) and were com-
pared with the values obtained one hour after normal deliv-
ery in 31 women without PPH.
Results:
A15 FIBTEM Fibrinogen (g/L) Control group n¼31 23,8 ¡Ó
1,02 4,58 ¡Ó 0,19
PPH Group T1 (n¼23) 20,2 ¡Ó 1,0* 4,2 ¡Ó 0,2
PPH Group T2 (n¼23) 16,06 ¡Ó 1,13** 3,4 ¡Ó 0,2**
Mann-whitney haemorrhage group versus control;
* p¼0,01; ** p,0,001,
At T1, A15 FIBTEM was significantly different between
patients who developped PPH and those who did not. At
T2, A15 FIBTEM and fibrinogen were significantly reduced in
the PPH group. We defined severe PPH according to our criter-
ias (decrease of hemoblobin .4 g/dl, transfusions, hemo-
static procedures). The T2 hemorrhage volum for the six
severe PPH differed significantly compared to the 17 mild
PPH (2066 ¡Ó 274 ml; 1267 ¡Ó 76 ml, p¼0,003). Severe PPH
ii191
BJA
presented lower T2 A15 FIBTEM and lower T2 fibrinogen com-
pared with mild PPH (p¼0,02 and 0,01 respectively).
Conclusion: At the time of PPH diagnosis, A15 FIBTEM sug-
gests a coagulopathy which is confirmed two hours later by
a decrease of fibrinogen. A15 FIBTEM could be used to iden-
tify hemostatic abnormality presents at the time of PPH and
may help to guide the management of severe PPH.
Reference
1 Charbit B. and al: The decrease of fibrinogen is an early predictor of
the severity of postpartum hemorrhage. J thromb Haemost 2007;
5: 266–73.
Paper No: 344.00
Post-partum haemorrhage induced
hypofibrinogenemia and fibrinogen
concentrates administration:
observationnal data of the
post-authorization study of Clottafact w
(LFB Les Ulis France)
Anne-Sophie Ducloy-Bouthors 1, Yves Gruel 2,
Jean Marie Grouin 3, Frederic Macaigne 4 and
Dominique Thiebaux 5
1
CHU Lille, Pole d’Anesthésie-Réanimation, Pole d’obstétrique,
Pole de Santé Publique, and Pole d’Hématologie Transfusion,
F-59000, 2 Laboratoire d’hémostase CHR Tours France, 3 Unite
biostatistiques universite Rouen France, 4 Laboratoire LFB Les Ulis
France, 5 Laboratoire LFB Les Ulis France.
Objectives: Observationnal safety study of fibrinogen con-
centrate adminsitration in post-partum haemorrhahe (PPH)
management in 12 French centers.
Méthod: Post authorization study of fibrinogen concentrate
Clottafactw (LFB les Ulis France). Out of 150 cases of acquired
hypofibrinogenemia collected over 6 Months, 59 were related
to PPH. Safety and clinical practice as well as biological data
were collected at 4 times: Inclusion¼H0, H1, H24, H72. Each
observation was validated by an expert committee.
Résults: Safety was good to excellent for all cases. PPH was
qualified as severe in 59% of the cases (median bleeding :
2230 ml [450-8000]) and 5 CGUA [0-24] Packed Red Blood
Cell were given to 47 (75%). The median dose of clottafact
used was 3g [1.5-4.5]. Clinically efficicency was qualified as
mild (n¼3), good (n¼36) and excellent and related to the
treatment (n¼4). However Most of the PPH were treated sim-
ultaneously regarding PPH management guidelines with
uterotonics (n¼22) or embolization-surgical ligature (n¼40)
or other procoagulant drugs as tranexamic acid (n¼14),
fresh frozen plasma (n¼37), platelets (n¼20) or rVIIa
factor (n¼8). Biological data showed a correction of fibrino-
gen plasma level from initial value at H0 :1.7+0.8 [1 à 2] g/
l to 2.1+0.8 g/l at H1. The fibrinogen plasma level at H24
ii192
Abstracts presented at WCA 2012
(3.7+1.3 g/l) and at H72 (5+2 g/l) were correlated to the
total dose administrered (p¼ 0.04 p¼ 0.01).
Discussion Conclusion: The decrease of fibrinogen is a known
predictor of PPH severity(1). However the efficacy of fibrino-
gen concentrates administration is poorly documented by
clinical cases (2) or substudies (3). This observational study
present a cohort of 59 PPH managed according to French
guidelines and receiveing simultaneously a median dose of
3g fibrinogen concentrates Clottafactw. Safety and biological
correction of hypofibrinogenemia are observed. These results
support the need of a randomised double blind study to
evaluate the contribution to the PPH associated coagulopa-
thy’s treatment.
References
1 Charbit JTH 2007; 5(2): 266–73
2 Bell IJOA 2010; 19: 218–23
3 Sorensen BJA 2008 101 (6): 769–73
Paper No: 345.00
Point-of-care prothrombin time testing as
an early predictor of severe post partum
hemorrhage
Anne-Sophie Ducloy-Bouthors 1, Alain Duhamel 1,
Clotaire Pilla 2, Catherine Barre 2 and Anne Bauters 2
1
Universite Lille Nord de France, EA2694 and EA2693, CHU Lille,
Pole d’Anesthésie-Réanimation, Pole d’obstétrique, Pole de Santé
Publique, and Pole d’Hématologie Transfusion, F-59000, 2 CHU
Lille, Pole d’Anesthésie-Réanimation, Pole d’obstétrique, Pole de
Santé Publique, and Pole d’Hématologie Transfusion, F-59000
Post partum hemorrhage is a major source of maternal mor-
bidity and is poorly predictable. The demonstration of a rela-
tionship between fibrinogen decrease and outcome suggests
that a near testing of coagulation might improve prediction
of outcome. The aim of our study was to test the reliability
of the point-of-care prothrombin time testing compared
with laboratory results in post-partum and to evaluate its
role in prediction of severe post partum hemorrhage (PPH).
After local ethic committee approval and informed consent,
95 patients (62 without PPH and 33 with PPH) patients
were enrolled for one blood sample 30 minutes after delivery
or at the beginning of immediate post-partum haemorrhage
before use of any uterotonics (T1). POC prothrombin time was
measured by CoaguChek XS Plus (Roche Diagnostics,
Germany). POC-prothrombin time (PT) and prothrombin
time ratio (PT ratio) were compared with central laboratory
values and with fibrinogen concentrations. The volume of
blood loss was recorded at T2 (T2¼ T1+2hours). The severity
of the PPH was defined according to the outcome of the first
24 hours. POC and laboratory PT and PT ratio were correlated
(r¼0.95 and 0.71 respectively; p,0.0001) and Bland and
Altman mean bias and accuracy respectively of 1.17 and
Abstracts presented at WCA 2012
4.97 for PT and 0 and 0.2 for PT ratio. POC-PT ratio was related
with fibrinogen concentration (r¼-0.4; p,0.001) and with
blood loss at T2 (r¼0.5; p,0.0001). Among women with
PPH, POC-PT ratio was significantly increased in severe ones
(0.9[09-1] vs 1[1-1.2]) p¼0.05). Considering the occurrence
of severe PPH, the area under the ROC curve was 0.81
(IC95% [0.68-093]; p,0.0001) for POC PT ratio values. The
cutoff value for POC PT ratio of 1.15 had the best prediction
specificity (100%). These ?ndings suggest that a simple POC
measurement could contribute to anticipate the risk of
severe bleeding in PPH.
Paper No: 346.00
Impact of perinatal care network on
post-partum hemorrhage –related
morbidity
Anne-Sophie Ducloy-Bouthors,
Jean-Claude Ducloy and Jerome Sicot
SAMU du Nord Reseau perinatal OMBREL Nord Maternite
Villeneuve d’ascq Reseau perinatal OMBREL CHU Lille, Pole
d’Anesthésie-Réanimation, Pole d’obstétrique, Pole de Santé
Publique, and Pole d’Hématologie Transfusion, F-59000
Background and goal of study Post-partum haemorrhage
(PPH) remains the leading cause of maternal morbidity and
mortality in France and worldwide. PPH can occur in any par-
turient. Perinatal care network is defined as a practioners’
and women’s hospitals’ association organizing mother and
child management around the birth period. The goal of our
medical practice improvement program (MPIP) was to stand-
ardize the management of PPH in every women hospital of
the network according to the French guidelines (1). The aim
of the study was to measure the impact of the MPIP on the
maternal morbidity due to PPH (2). Materials and methods
The MPIP realized a synthesis and the edition of the manage-
ment guidelines, the critical care chart and the educational
material of the training team in common between the 11
low risk women’s hospitals. Midwives, paramedics and
medical doctors were trained to evaluate the practice com-
paring the results obtained in 2006 after MPIP to 2004
before MPIP. Collected data were the delay and the protocol
of management and their impact on the maternal morbidity
due to PPH.
Results: Out of 20 619 deliveries 259 PPH were detected in
2006 vs 189 out of 21 373. No hysterectomy or death
related to PPH occurred. Thirteen parturients vs 16 were
transferred to the obstetrics ICU. Transfer delay was signifi-
cantly shorter. None of these 13 parturients had haemor-
rhagic shock vs 5 in 2004. Transfusion was performed in
two vs 5, procoagulant complementary treatment to 4 vs 9
and uterine arteries embolization in 2/13 vs 7/16 parturients.
Quite all the parturients (12/13) transferred in 2006 were dis-
charged from obstetrics ICU after 12 hours vs 11/16 in 2004.
BJA
Discussion Conclusion: Despite the limited number of cases,
it can be observed a trend to a better detection of HPP and to
a better and more rapid management of PPH in the primary
care units. This better primary management could explain
the reduction of transfusion, procoagulant treatment and
embolization needed in the tertiary care leading to quicker
discharge from obstetrics ICU and less maternal morbidity.
Improving the obstetrics care at the nearest of the patient
could be the new challenge for maternal risk management
as suspected in ICM and FIGO joint guidelines (3) and in
the 6 French perinatal networks preliminary analysis (4).
The perinatal care network Medical Practice Improvement
Program leading to an initial aggressive management of
PPH could avoid the evolution to severe maternal morbidity.
References
1 French guidelines for post-partum haemorrhage management.
J Gynecol Obstet Biol Reprod 2004; 33; 8 Suppl.
2 Bally B. Ann Fr Anesth Réanim 2006; 25: 356– 361
3 Prevention and treatment of Post-partum Haemoorhage. New
advances for low resource settings. Int J Gynecol Obstet 2007;
97: 160–163.
4 Deneux-Tharaux C, J Gynécol Obstét Biol Reprod 2008; 37:
237–245.
Paper No: 347.00
Preeclampsia as a risk factor for Postnatal
Pulmonary Embolism
Anne-Sophie Ducloy-Bouthors, Benedicte Wibaut,
NathalieTrillot, PhilippeDeruelle and MarcLambert
CHU Lille, Pole d’Anesthésie-Réanimation, Pole d’obstétrique, Pole
de Santé Publique, and Pole d’Hématologie Transfusion, F-59000
Objective: Pulmonary embolism (PE) remains the cause of
10% of maternal mortality in France. Out of a 10 years
survey of thrombo-embolic events in a French tertiary care
obstetric unit in a population of 44 198 pregnancies prevent-
ively managed according national and international guide-
lines, risk factors for post-partum pulmonary embolism
were identified.
Study design: In this 1999-2009 register-based observational
study, Deep Vein Thrombosis (DVT) and EP were analyzed in
order to assess the thromboprophylaxis protocol: Each preg-
nant woman was checked for her familial and personal
thrombosis risk factors. In the high risk group, LMWH were
prescribed ante and postnatally whereas only postnatally in
the moderate risk group (1,2). Pulmonary embolism was clin-
ically detected and confirmed by angioscanner.
Résults: Out of a population of 44198 deliveries, 1353 pre-
eclampsia and 1284 patients with thrombotic risk factors,
108 thromboembolic events were noted. (0.244% [95% CI
0.198-0.290]): DVT (n¼67) and PE (n¼41). Out of the 49
DVT and 29 antenatal EP, none occurred in high risk patients
under adequate LMWH, except for 4 out of the 16 patients
ii193
BJA
with AT deficiency. Postnatal PE occured in 12 patients
(0.027% [95% CI 0.012-0.043]). Six of them occurred in pre-
eclamptic patients (0.443% [95% CI 0.16-0.96]). The relative
risk of PE in preeclampsia was 31.67 [95% CI 10.23-98.06]).
Associated risk factors of PE in preeclampsia were caesarean
section (CS)(n¼4), older age and multiparity (n¼3), obesity
(n¼1) and thrombophilia (n¼1). The 4 EP after CS occurred
under low dose LMWH.
Discussion and Conclusion: Preeclampsia is a known throm-
bosis risk factor (3,4), probably induced by the hypercoagul-
able state. The risk of pulmonary embolism after
preeclampsia appears to be more than ten times higher
than after a normal delivery following a normal pregnancy
in our population. Non-adapted doses of LMWH did not
prevent PE in these patients. Biological efficacy of LMWH
and/or thrombin generation monitoring may be useful in
these patients to guide the clinicians.
References
1 Chest 2008; 133;844–886
2 French guidelines SFAR 2005
3 Jacobsen AF, Am J Obstet Gynecol 2008; 198: 233.
4 Knight M on behalf of UK OSS. BJOG 2008; 115: 453– 461.
Paper No: 354.00
Spinal anesthesia for cesarean section.
Comparative study between ropivacaine/
fentanyl and bupivacaine/fentanyl
Paola Carrozzini 1, Fernando Godoy 2,
Guillermina Harvey 3, Dario Colucci 4 and Nora Puig 5
1
Hospital Cullen, Santa Fe, Argentina, 2 Hospital Cullen, Santa Fe,
Argentina, 3 Carrera de Anestesiologœa, Fac. Cs, 4 Carrera de
Anestesiologœa, Fac. Cs, 5 Carrera de Anestesiologœa, Fac. Cs
Introduction: Ropivacaine is along-acting, local anesthetic,
less cardioneurotoxic than bupivacaine, with similar duration
of action. Compared to bupivacaine, ropivacaine, at equipo-
tent doses, provide effective spinal anesthesia with shorter
duration of motor block.
Objective: To evaluate the latency and duration of the sensi-
tive (T6) and motor block, hemodynamic variables and
adverse effects in patients receiving spinal anesthesia for ce-
sarean section, comparing 75% isobaric ropivacaine 15 mg
plus fentanyl 25 ug/ml and 0.5% hyperbaric bupivacaine
10mg plus fentanyl 25 ug/ml intrathecally.
Methods: Ethics Committee approved, prospective, aleator-
ized, simple blind study.
Patients: 40 full-term women without analgesia in course,
ASA I and II, elective or urgency (not emergency) cesarean
section under spinal anesthesia. After informed consent,
patients were randomly allocated to receive intrathecally:
75% isobaric ropivacaine 15 mg plus fentanyl 25 ug/ml
(group RF), or 0.5% hyperbaric bupivacaine 10mg plus
ii194
Abstracts presented at WCA 2012
fentanyl 25 ug/ml (group BF). Sensitive blockage was evalu-
ated by the pinprick and Hollmen tests, and the motor
block by the Bromage scale. Maternal side effects were also
recorded.
Monitoring: Heart rate, systolic and diastolic arterial pres-
sure, recorded every 2 min up to min 20. When blood pres-
sure decreased 20% from the baseline value, patients
received IV ephedrine (5 mg) boluses. Data is presented as
mean+standard deviation or as percentages when appropri-
ate. Comparisons between groups were performed by using
the Mann-Whitney U-test, the Pearson 42 test or the Irwin-
Fisher test. The significance level was set at 0.05.
Results: There were no statistical differences in demographic
data between groups: Age, weight, height, number of previous
cesarean deliveries, percentage of scheduled surgeries, per-
centage of ASA I patients, and surgical procedure duration
(min.) RF: 39.4+8.1, BF: 35.3+6.6; p¼0.07. Anesthesia was
satisfactory in all patients. Latency to T6 level (min.) was
lower in RF (2.5+0.5, BF: 3.8+1; p,0.001). Maximal sensory
block: 85% T4/15% T5 in both groups, p¼0.67. Sensorial
block duration (min) RF: 155.8+21.2, BF: 159.5+20.8;
p¼0.56. Motor blockade was complete in all patients, duration
up to Bromage I (min.): RF: 105+19.8, BF: 116.5+9.6; p¼0.08.
Lower frequency of hypotension in Group RF 3/20, BF: 9/20;
p¼0.04, with similar ephedrine requirements: 5 to 10 mg,
p¼0.54. No patient required atropine. Incidence of pruritus:
RF 6/20; BF 8/20; p¼0.51, with a case of nausea in the BF
group. No local or systemic toxicity was observed.
Conclusions: Treatments offered comparable sensitive and
motor blockage. Clinical advantages of ropivacaine/fentanyl
result from the shorter latency and lower incidence of
hypotension.
Paper No: 369.00
Anaesthesia for Cesarean section in a
patient with overlap syndrome: a case
report
Huda Alfoudri, Najat Dehrab and
Abdulrahman Alrefae
Maternity Hospital, Kuwait city, Kuwait University Hospital Wales,
Cardiff, United Kingdom Maternity Hospital, Kuwait city, Kuwait
Introduction: Primary biliary cirrhosis is rare during preg-
nancy. There are few case reports in the literature that de-
scribe primary biliray cirrhosis in pregnancy that either first
presented during pregnancy or was diagnosed prior to preg-
nancy. We describe a 45-years-old para 1 patient who was
diagnosed with an overlap syndrome of autoimmune hepa-
titis and primary biliary cirrhosis.
Objectives: To Describe the presentation and anaesthesia for
Cesarean Section in a patient with an overlap syndrome
Methods (case presentation): A 45 years old para1 patient
presented to the antenatal clinic at 32 weeks gestation
Abstracts presented at WCA 2012
with increased pruritis, nausea and lower limb oedema. Her
past medical history included cholycystectomy and a diagno-
sis of an overlap syndrome 18 months ago based on a posi-
tive antimitochondria antibody (AMA) and liver biopsy she
has been started on ursodeoxycholic acid 250 mg three
times daily and was under regular follow up by the hepatol-
ogist. She remained stable throughout pregnancy up to this
presentation where she was found to have pancytopaenia
due to hypersplenism. Her Hb, WBC, and platelets were
7.8g/dl, 3.4, and 60 respectively. Her liver function tests
revealed a raised bilirubin (119) with a mildly deranged
liver enzymes, albumin 22 and INR 1.54. Abdominal USS
revealed liver cirrhosis, hepatosplenomegaly with dilated
splenic vain but no ascites. In addition, there were decreased
fetal movement. Initially she was managed conservatively
with piriton, albumin replacement, vitamin K, RCC and plate-
let transfusion. Her ursodeoxycholic acid dose was increased
to 500mg three times daily. 2 weeks after admission a repeat
abdominal USS revealed absent diastolic flow and therefore
decision for cesarean section was made. As she remained
coagulopathic a decision was made for a general anaesthetic
with rapid sequence induction after antacid prophylaxis and
transfusion with RCC, FFP, and platelets. The surgery was un-
eventful and a live baby girl was delivered weighing 1.96kg
with an Apgar score of 7 and 8. The patient was kept in
high dependency unit for 48 hours post-operatively where
she made full recovered. She eventually was discharged
from the hospital one week later after improvement in prur-
itis, LFTs, and coagulation with follow up by the hepatologist.
Conclusion: Patients with overlap syndrome rarely present
during pregnancy and therefore experience in dealing with
them may be limited. General anaesthesia is more
common for these patients as they are often coagulopathic.
However GA carries many risks including clinical decompen-
sation in patients with cirrhosis and this has to be monitored
and managed appropriately.
Paper No: 387.00
Effective dose of oxytocin in caesarean
delivery
Shashi Kiran 1, Asha Anand 1, Tarandeep Singh 1
and Neha Gupta 2
1
PGIMS, Rohtak, India2 MM Medical College, Mullana, India
Introduction: Patients undergoing caesarean delivery are at
increased risk of obstetric haemorrhage. Uterine atony has
been shown to be most common aetiology (30%) for post
partum haemorrhage (PPH) in patients undergoing caesar-
ean delivery. Use of uterotonic agents decreases the inci-
dence of PPH by approximately 40% when compared with
placebo. Oxytocin is the most frequently used uterotonic
BJA
agent because of less side- effects compared with all other
available agents. Despite widespread use, there are limited
data to guide optimal oxytocin dosing for patients undergo-
ing elective caesarean delivery for achieving adequate
uterine tone with minimal side effects. Objectives Tthe
study was conducted to evaluate three doses of oxytocin
required to produce adequate uterine tone in primigravidas
undergoing elective caesarean delivery.
Methods: This randomized double blind study was conducted
in ninety primigravidas undergoing elective caesarean deliv-
ery under spinal anaesthesia. All patients received intraven-
ous bolus of either 0.5, 1, or 2 IU oxytocin followed by
infusion of 10 IU hr-1. Uterine tone was assessed by a
blinded obstetrician using a five-point scale, where
1¼atonic, 2¼partial but inadequate contraction, 3¼
adequate contraction, 4¼well contracted and 5¼very well
contracted at 2, 3, 6, and 9 min after oxytocin administration.
The effect of oxytocin doses was analysed. Oxytocin related
side-effects were recorded. All the data was compiled and
analysed statistically using Analysis of Variance (ANOVA)
test for haematocrit, need for additional uterotonic agents
and the amount of blood loss. Chi-square test was used to
analyse heart rate, non invasive blood pressure and the
side effects of oxytocin. A p value of ,0.05 considered sig-
nificant, ,0.01 considered highly significant and .0.05
was taken non significant.
Results: There were no significant differences in the preva-
lence of adequate uterine tone among the study groups at
2 min (86%, 90% and 93% for, 0.5, 1 and 2 IU oxytocin,
respectively(p.0.05). The estimated blood loss & difference
in preoperative and postoperative haematocrit values were
also non significant(p.0.05). No hypotension and tachycar-
dia was observed in any group at any time. The prevalence of
nausea and vomiting was significantly higher after 2 IU oxy-
tocin vs 0.5 IU at 1 min (13% vs 3%; p ,0.05%).
Conclusion: Small bolus doses of oxytocin (0.5-2 IU) result in
adequate uterine tone in primigravida women undergoing
elective caesarean delivery with minimal effects on haemo-
dynamic parameters. However use of 2 IU oxytocin is asso-
ciated with more incidence of nausea and vomiting.
References
1 Thomas JS, Koh SH, Cooper GM. Haemodynamic effects of oxytocin
given as i.v. bolus or infusion on women undergoing caesarean
section. Br J Anaesth 2007; 98: 116–9.
2 Pinder AJ, Dresner M, Calow C, Shorten GD, O’Riordan J, Johnson R.
Haemodynamic changes caused by oxytocin during caesarean
section under spinal anesthesia. Int J Obstet Anesth 2002; 11:
156–9.
3 Dyer RA, Dyk DV, Dresner A. The use of uterotonics during caesar-
ean section. Int J Obstet Anesth 2010; 19: 313– 9.
4 Tsen LC, Balki M. Oxytocin protocols during caesarean delivery:
time to acknowledge the risk/benefit ratio? Int J Obstet Anesth
2010; 19: 243–5.
ii195
BJA
Paper No: 418.00
Hemodynamic effects of a right lumbar –
pelvic wedge during spinal anesthesia for
cesarean section
Jose Andres Calvache, Manuel Felipe Muñoz and
Francisco Baron
Background: Aortocaval compression is a major cause of ma-
ternal hypotension. A randomized controlled trial was
designed to determine the effectiveness of a mechanical
intervention using a right lumbar–pelvic wedge in preventing
hypotension after spinal anesthesia for cesarean delivery.
Methods: Eighty healthy women undergoing elective cesar-
ean section were randomly allocated immediately after
spinal blockade to either a lumbar–pelvic wedge positioned
under the right posterior–superior iliac crest (Wedge group,
n¼40) or the complete supine position (Supine group,
n¼40). Hemodynamic values, vasopressor consumption
and adverse effects were collected during the surgical pro-
cedure. Hypotension was defined as a reduction in systolic
blood pressure of 25% from baseline. Patient allocation,
management and data collection were performed by a
single unblinded anesthetist.
Results: There was no difference in the incidence of hypoten-
sion between the two groups (42.5% vs. 50%, P¼0.51).
During the first 5 min, blood pressure decreased less in the
Wedge group. There were significant differences in median
[interquartile range] vasopressor requirements between the
Wedge group and the Supine group (1 [0– 2] vs. 3 [1–4]
mg, P,0.01) and in nausea during the procedure (6 vs. 22
patients, P,0.01).
Conclusion: In our study population the use of right lumbar–
pelvic wedge was not effective in reducing the incidence of
hypotension during spinal anesthesia for cesarean section.
Patients in whom the wedge was used had higher systolic
blood pressure values during the first 5 min of anesthesia
and fewer episodes of nausea. The risk of hypotension
remains substantial.
Paper No: 457.00
Systemic versus intrathecal morphine on
postoperative analgesia in Caesarea.
Randomized Trial study in two centers from
Cordoba, Argentina
Roberto Guillermo Santiago
Introduction: Postoperative analgesia in cesarean section,
relegated to consideration by the anesthesiologist, is not a
standard practice. The low-dose intrathecal morphine is an
effective analgesic method, which records in Argentina
ii196
Abstracts presented at WCA 2012
didn’t know. This research was developed compared with sys-
temic regulated administration.
Objectives: Demonstrate that low-dose intrathecal morphine
offers better quality analgesia with minimal adverse
reactions.
Materials and Methods: Experimental randomized double-
blind trial whit ASA 1 and 2 patients under spinal anesthesia,
MIT Group: 0.5% hyperbaric bupivacaine 10 mg plus 100 mcg
intrathecal morphine; MEV Group: 0.5% hyperbaric bupiva-
caine 10 mg plus intravenous morphine regulated. We evalu-
ated analgesics parameters, adverse reactions and fetal
well-being up to 24 hours. We used Student T-test unpaired,
U Mann-Whitney test, chi-square, setting an alpha error of
0.05 and a power of 80%.
Results: Recruited 263 patients, Groups: MEV: 133 patients
and MIT: 130 patients, found similar anthropometric charac-
teristics, surgical and anesthesia times, hemodynamic vari-
ables and fetal wellbeing. We didn’t record respiratory
depression or sedation. MIT VNS (Verbal Numeric Scale)
median and range()was lower at time 0 hs. 0(0) vs. MEV
0(6) p:0.002; 3hs. MIT 0(9) vs. MEV 1(10) p:0.000; 6hs. MIT
0(9) vs. MEV 1(10) p: 0.000; 9 hs. MIT 0(7) vs. MEV 1(8) p:
0.000; 12 hs. MIT 0(8) vs MEV 0(9) p: 0.000; 24hs. MIT 0(8)
vs. MEV 0(10) p: 0.032. At MIT group found lower rescue mor-
phine dose 0.72 mg. DS 1.75 p: 0.000, Relative Risk Reduction
of VNS.3: 0.65 IC95 (0.475-0.778) p ,0.001 and NNT of 3.2
with greater maternal satisfaction MIT 67% vs. MEV 52% p¼
0.006. MIT itching occurred in 23% but only 9.1% required
treatment versus 0.8% in MEV p¼ 0.000. MIT nausea and
vomiting developed in 13.08%, but the 7.08% required treat-
ment, while MEV presented in 7.5% p¼0.075.
Discussion: Intrathecal morphine demonstrated superior
quality analgesia at the expense of an increase in adverse
reactions, which were mostly mild and tolerable, as
expressed in the greater maternal satisfaction in this
group. Significantly, there was no increased sedation or re-
spiratory depression. These findings are similar to the litera-
ture. Both techniques were safe for the baby, which is related
to morphine and its pharmacokinetics.
Conclusions: The results of this study give the low-dose intra-
thecal morphine (mini-dose) higher quality analgesia with
acceptable side effects, making it a recommended
technique.
Keywords: Intrathecal morphine; Systemic morphine; Caesa-
rea; Postoperative analgesia; Adverse Reactions
References
1 Gehling M, Tryba M: Risks and side-effects of intrathecal morphine
combined with spinal anaesthesia: a meta-analysis. Anaesthesia,
2009; 64: 643–65.
2 George RB, Allen TK, Habib AS: Serotonin Receptor Antagonists for
the Prevention and Treatment of Pruritus, Nausea, and Vomiting in
Women Undergoing Cesarean Delivery with Intrathecal Morphine:
A Systematic Review and Meta-Analysis. Anesth Analg;109: 174–
82; 2009.
3 Girgin NK, Gurpert A, Turker G et al. Intrathecal morphine in anes-
thesia for cesarean delivery: dose-response relationship for
Abstracts presented at WCA 2012
combinations of low-dose intrathecal morphine and spinal bupiva-
caine. Journal of Clinical Anesthesia; 20: 180 –185, 2008.
Paper No: 491.00
Supplementary oxygen during elective
caesarean section under spinal
anaesthesia
Wan Salwanis 1, Wan Ismail 1 and Choon Yee Lee 2
1
Ipoh Hospital, Ipoh, Malaysia, 2 Universiti Kebangsaan Malaysia
Medical
Introduction: During spinal anaesthesia for Caesarean
section (CS), there are reductions in maternal peak expiratory
flow rate, forced vital capacity, and forced expiratory
volume.[1] Oxygen supplementation is commonly provided,
even though maternal oxygen saturation is well maintained
despite these respiratory changes. The benefit of oxygen sup-
plementation is controversial, as increase in markers of free
radical activity had been shown in the neonates born to
mothers breathing oxygen enriched air [2].
Objectives: This prospective randomized double-blinded
study was carried out to compare the effects of oxygen sup-
plementation on neonatal outcome (Apgar scores at 1
minute and 5 minutes, umbilical artery and vein pH) in elect-
ive CS under spinal anaesthesia. The neonatal outcomes in
patients with prolonged skin incision-delivery (I-D) and
uterine incision-delivery (U-D) intervals were also compared
with those of their counterparts.
Methods: Eighty two ASA I or II patients scheduled for elect-
ive CS under spinal anaesthesia were recruited. Following
subarachnoid blocks using standard protocol, they were ran-
domized into Group A (n¼40) breathing room air, and Group
B (n¼42) breathing 6 L/min of oxygen via Hudson mask. Ma-
ternal haemodynamic parameters and oxygen saturation
were closely monitored. Patients in Group A who developed
SpO2,97% would be given oxygen supplementation and
excluded from the study. The times of skin incision, uterine
incision and delivery were recorded. Apgar scores at 1
minute and 5 minute were assessed by paediatric medical
officer or staff nurse blinded to the patient’s group allocation.
Blood samples from umbilical artery and umbilical vein were
collected and analyzed.
Results: No statistically significant differences were observed
in maternal oxygen saturation, Apgar scores, as well as um-
bilical artery and vein pH between the two groups. The
patients were sub-divided into short (, 10 minutes) and
long (.10 minutes) I-D intervals, as well as short (,3
minutes) and long (.3 minutes) U-D intervals. No significant
differences in umbilical artery and vein pH were observed in
these sub-groups.
Conclusions: In patients undergoing elective CS and in the
absence of fetal compromise, no differences in maternal oxy-
genation and neonatal outcome could be demonstrated
BJA
whether or not oxygen supplementation was administered
intraoperatively.
References
1 Kelly MC, et al. Respiratory effects of spinal anaesthesia for caesar-
ean section. Anaesthesia 1996; 51: 1120–2.
2 Khaw KS, et al. Effects of high inspired oxygen fraction during
elective Caesarean section under spinal anaesthesia on maternal
and fetal oxygenation and lipid peroxidation. Br J Anaesth 2002;
88(1): 18 –23.
Paper No: 500.00
Uterotonic efficacy of oxytocin 2.5 versus
10 units during caesarean section at
mulago hospital: a double blinded placebo
controlled randomised clinical trial
Andrew Kintu, Sarah Nakubulwa, Cephus Mijumbi,
Arthur Kwizera and Joseph Tindimwebwa
Makerere University College of Health Sciences Department of
anaesthesia, Kampala Uganda
Introduction: Oxytocin is routinely administered during Cae-
sarean section Delivery (C/S) to initiate and maintain ad-
equate uterine tone (UT) and reduce blood loss after
placenta delivery. Oxytocin is however associated with un-
wanted effects namely; tachycardia, hypotension, ECG
changes, chest pain, nausea and vomiting. The magnitudes
of these changes are dose dependant. In Uganda, 10 units
of Oxytocin is still being used, yet smaller doses have been
shown to be effective at achieving adequate uterine tone
and reducing blood loss with fewer side effects.
Objective: To determine whether 2.5 I.U of Oxytocin gives ad-
equate uterine tone and is safe as compared to 10 I.U of
Oxytocin following caesarean section delivery at Mulago
hospital.
Methods: After obtaining institutional approval, 380 Mothers
undergoing both emergency and elective caesarean section
delivery(C/S) in obstetric theatres of Mulago hospital that fit
the inclusion criteria were randomized to receive either 2.5
units or 10 units of Oxytocin after clamping of the umbilical
cord. The primary outcome was adequacy of uterine tone
(UT). Others were heart rate (HR), BP, Blood Loss, as well as
requirement of additional uterotonics.
Results: 94.71% had adequate Uterine tone in 2.5 unit group
compared 88.89% in the 10 unit group at 2 minutes. There
was no statistically significant difference in requirement for
additional uterotonics in both groups (p- value 0.119),blood
loss, frequency of vomiting (p¼0.653), nausea (p¼0.398),
haemodynamic changes and chest pain (p¼0.738)
between the two treatment groups.
Conclusion: 2.5 I.U of Oxytocin gives adequate uterine tone
and is safe when compared to 10 IU of Oxytocin following
caesarean section delivery at Mulago hospital.
ii197
BJA
Recommendation: The routine use of 10 IU of oxytocin
during both elective and emergency caesarean section deliv-
ery should be revised since adequate uterine tone can be
achieved with 2.5 units
References
1 Thomas JS, Koh SH, Cooper GM: Hemodynamic effects of oxytocin
given as i.v. bolus or infusion on women undergoing Caesarean
section. Br J Anaesth 2007; 98: 116– 9.
2 Pinder AJ, Svanström MC, Biber B, Hanes M, Johansson G,
Näslund U, Balfors EM. Signs of myocardial ischaemia after injec-
tion of oxytocin: a randomized double-blind comparison of oxyto-
cin and methylergometrine during Caesarean section. Br J
Anaesth 2008; 100: 683 –9
3 Jonsson M, Hanson C, Lidell S Norden Lideberg. ST depression at
caeserean section and the relation to oxytocin dose. A rando-
mised controlled trial. BJOG 2010; 117: 76–83
4 Why Mothers Die 1997–1999. Report on Confidential Enquiries
into Maternal Deaths in the United Kingdom. London: RCOG
Press: 134– 49.
5 Slater RM, Bowles BJM, Pumphrey RSH. Anaphylactoid reaction to
oxytocin in pregnancy. Anaesthesia, 1985; 40: 655 –656
6 Chilvers JP, Cooper G, Wilson M. Myocardial Ischaemia complicat-
ing an elective caeserean section. Anaesthesia 2003; 58: 822– 3
7 Weis FR Jr., Markello R, Mo B, Bochiechio P. Cardiovascular effects
of oxytocin. Osbstet Gyeocol 1975; 46: 211– 4
8 Lin MC, Hsieh TK, Liu CA, Chull Chen JY, Wang JJ. Anaphylactoid
shock induced by oxytocin administration- a case report. Acta
anaesthiol Taiwan: 2007; 45 (4) 233 –6
9 Butwick AJ et al., Minimum effective bolus dose of oxytocin
during elective Caesarean delivery. Br. J. Anaesth. (2010) 104
(3): 338–343.
10 Sartain JB, et al., Intravenous oxytocin bolus of 2 units is superior
to 5 units during elective Caesarean section. Br J Anaesth 2008.
101: p. 822–6.
11 Howard Fee JP, Bovil James G: Pharmacology for the Anaesthesiol-
ogist.: 2005; Pg 201: Great Britain the Bath Press
12 Rosaeg OP, Cicutti NJ, Labow RS. The effect of oxytocin on the
human atrial trabeculae. Anaesth. Analg 1998; 86: 40– 4
13 Carvalho JCBJ, Windrim R. Oxytocin dose requirement at elective
ceaserean delivery a dose finding study. Obstet Gynaecol 2006;
107: 45 –50
Paper No: 541.00
Gestational trophoblastic disease: a review
of the anesthetic management of 181
clinical cases of molar pregnancy
Samantha Russell, Gladness Nethathe and
Fathima Paruk
Intensive Care Unit, University of the Witwatersrand Department
of Anaesthesiology, University of the Witwatersrand Department
of Anaesthesiology, University of the Witwatersrand
Introduction: Molar pregnancy is associated with significant
morbidity (1,2). The anesthetic management is predominant-
ly expert opinion based.
ii198
Abstracts presented at WCA 2012
Objectives: To (i) ascertain the number of cases of molar preg-
nancies surgically managed at the 3 major academic hospi-
tals of the University of Witwatersrand, South Africa from 1
January 2007 to 31 March 2011, (ii) describe their anesthetic
management, (iii) determine the associated complications.
Methods: A retrospective record review following approval
from the University research ethics committee. Data cap-
tured included demographic factors, clinical presentation,
investigations, anesthetic management, complications and
hospital stay. The cases were divided into 2 groups. Group
I:,20 weeks uterus size and Group II:.20 weeks uterus size.
Results: One hundred and eighty case records were retrieved
of the 200 cases managed during the study period. The
mean age was 27.7 +7.4 years. There were 143 and 38
cases in Group I and Group II respectively. In Group I the in-
cidence of biochemical and clinical hyperthyroidism was
19.6% (23/ 117) and 7.7% (9/117) respectively. Blood transfu-
sion was indicated in 15.1% (21/139). 1.04% (2/142) had
sepsis. General anesthesia (GA) was administered in
92.3%(127/143) of cases. 35% (45/127) of the GA cases
had a definitive airway (endotracheal tube) secured.
84.4%(38/45) of these were performed under a rapid se-
quence induction (RSI). 64.6% of the GA cases had supraglot-
tic airways placed. 7.7% (11/143) of cases had neuraxial
anesthesia. The complication rate was 14%. Three cases
required high care and 1 case required intensive care post op-
eration. In Group II the incidence of biochemical and clinical
hyperthyroidism was 38.2%(13/34) and 23.5% (8/34) respect-
ively. Blood transfusion was indicated in 40.5%(15/37). 78.9%
(n¼38) had a GA. 41.7% (15/36) of the GA cases had a defini-
tive airway secured. 38.9% of these were performed under a
RSI. 38.9% (14/36) of the GA cases had supraglottic airways
placed. 18.4% (6/38) cases had neuraxial anesthesia with 2
having sedation. The complication rate was 31.6%. Four
cases required high care and 1 case required intensive care
post operation. The mean hospital stay was 4.7+7.4days
and 4.8+3.8days for Groups I and II respectively.
Conclusion: The occurrence of anemia and hyperthyroidism
is high in this patient group. The associated complications
are substantial. Research Agenda: Anesthetic management
for molar gestations needs to be standardized.
References
1 Soper JT. Gestational Trohpoblstic Disease. Clinical expert series.
108(1) July 2006: 176–187
2 Seckl MJ, Sebire NJ, Berkowitz RS. Gestational trophoblastic
disease. The Lancet 2010. 376: 717– 729
Paper No: 556.00
Pain after cesarean section - a significant
clinical problem?
Hanke Marcus 1, Sanjay Aduckathil 2,
Winfried Meißner 3, CJ Kalkman 4 and
Hans Jürgen Gerbershagen 5
Abstracts presented at WCA 2012
1
University Hospital of Cologne, Department of Anesthesiology
and Intensive Care Medicine, Cologne, Germany, 2 University
Hospital of Cologne, Department of Anesthesiology and Intensive
Care Medicine, Cologne, Germany, 3 University Hospital of Jena,
Department of, 4 Division of Anesthesiology, Intensive Care and,
5
Division of Anesthesiology, Intensive Care and
Introduction: Pain is an often-underestimated negative
outcome after cesarean section (CS). Several randomized
controlled trials investigated different analgesic regimens
after CS. Unfortunately, however, RCTs rarely do present the
typical course in acute postsurgical pain of patients with co-
morbidities or chronic preoperative pain conditions and other
typical RCTs exclusion criteria. In this study the relevance of
acute pain after CS is analyzed.
Methods: We compared pain intensities after CS with post-
operative pain intensities of patients after 179 different op-
erative procedures including all common surgical
procedures in all surgical fields. Patients were investigated
on the first postoperative day using a validated 15-item
questionnaire. In addition, important anesthesiological, sur-
gical, and pain therapy-related variables were recorded.
These data were collected in surgical departments of 105
hospitals within the framework of the German QUIPS
project (Quality Improvement in Postoperative Pain
Therapy, www.quips-project.de).
Results: We compared the quality of postoperative pain
therapy of 824 patients after CS from 35 different hospitals
with that of patients after 179 different operative procedures
(n¼49699). The worst pain intensity during the first 24 hours
after CS was 6.2 (SD 2.3) on a numeric rating scale (NRS
0-10). Pain after CS ranked no. 6 compared with all 179 pro-
cedures. The intensity of pain during movement was NRS 5.2
(SD 2.2) and ranked 8th position. 19.3% of the patients had
received a patient-controlled intravenous analgesia (PCIA).
Pain ratings were not significantly lower in the PCIA group.
The question if patients would have liked to have additional
analgesics during the last 24 hours was answered in the af-
firmative by 14.2% of the patients (62nd position) (all 179 op-
erative procedures 12.4%, range 0%-33.3%). The overall
satisfaction with pain therapy was rated as NRS 12.4 (SD
2.5) on a NRS from 0 to 15.
Conclusions: Our data analysis suggests that CS is one of the
most painful surgical procedures necessitating the attention
of the whole medical team. Patients’ satisfaction with regard
to pain management has to be improved. We did not
examine the multiple causes of the severity of post-CS
pain. The data clearly show that neither PCA, systemic
analgesics nor peridural analgesia have been employed opti-
mally for postoperative care in CS patients. Interestingly,
patients with a PCIA device did not have lower pain ratings.
This my be due to underutilizing. The well-known risk
factors ‘younger age’ and ‘female gender’ may contribute
to the high pain ranking. Apart from surgical factors the
reason for severe pain after CS could be due to the lack of
knowledge of the health personal or a mother’s conflict
with breastfeeding.
BJA
Paper No: 569.00
Maternal position during caesarean section
for preventing maternal hypotension: a
survey of our practice
Dominique Chassard, Pauline Brun, Celine Guichon
and Mariette Hirat
Hospices Civils de Lyon, Hopital mere enfant, 69500 Bron, France
Background: Many anaesthesiologists believe that adjusting
the position of the woman during caesarean section may
improve the outcome for both the mother and baby. The
theory behind this is based on beliefs that tilting the table
laterally may prevent aortocaval compression. The common
recommendation is a 158 lateral tilt. Other practitioners
believe that there is no difference and that tilting the table
makes the surgery more difficult. The aim of this study was
to record the angle of table tilt used in our institution
during elective Caeserean section in non complicated, single-
ton pregnancies.
Methods: The measurements were randomly distributed in
time to avoid a change in practice. One anaesthesiologist
of our team initiated spinal anaesthesia (8-10 mg
bupivacaine+ 5 mg sufentanil+100 mg morphine) and gave
routine prophylactic treatment of hypotension in use in our
institution (500 mL of lactated Ringer’s solution+ephedrine
3 mg/mL+phénylephrine 50 mg/mL. Vasopressors were
administered by an infusion pump at a rate of 20 to 50 ml/
h to maintain arterial pressure.80% baseline measure-
ments). A second anaesthesiologist, not involved in anaes-
thesia, recorded the blood pressure, needs for vasopressors
and recorded the angle of tilt. The angle was measured
with an iPhone application (Clinometerw). Results are
expressed as mean+S.D.
Results: fifty two women were enrolled in this study. Age was
32+5 yr, weight 71+12 kg and height 161+7 cm. Twenty
patients received 8 mg of bupivacaine, 6 received 9 mg and
26 received 10 mg. The mean volume of vasopressors admi-
nistered before delivery was 12+4 mL. The mean angle of
table tilt was 6.2+4.38. The angle was,58 in 26 patients,
ranged from 6 to 108 in 16 patients, from 118 to 128 in 7
patients and was between 138-158 in only 3 patients. No sig-
nificant correlation was found between the dose of vasopres-
sors needed and the angle of table tilt.
Conclusion: Recommendation for 158 tilt during Caesarean
section is of little use in our institution. This survey is in ac-
cordance with recent Cochrane Library Review who con-
cluded that tilting the patient has no proven effect on
maternal hemodynamic (1).
Reference
1 Cluver C, Novikova N, Hofmeyr GJ, Hall DR. Maternal position during
caesarean section for preventing maternal and neonatal compli-
cations. The Cochrane Database of Systematic Reviews 2011,
Issue 7.
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BJA Abstracts presented at WCA 2012

Paper No: 571.00 Reference

1 Pilkingston S et al. Br J Anaesth 1995, 74: 638–42

Mallampati score during pregnancy Paper No: 573.00

Dominique Chassard and Diane Le Quang
Hospices Civils de Lyon, Hopital Mere Enfant, 69500 Bron, Farnce Neck ultrasonography and mallampati
scores in pregnant patients
A previous study demonstrated that airway edema can in- Boris Bryssine 1, Dominique Chassard 2 and
crease during the course of pregnancy resulting in an
Diane Le Quang 3
increased Mallampati score (1). Recently, a study showed
1
that labor and delivery are associated with further airway Hospices Civils de Lyon, HFME, Bron, France 2 Hospices Civils de
Lyon, CHLyon Sud, Lyon, France 3 Hospices Civils de Lyon, HFME,
changes compared with prelabor (2). Acoustic reflectometry
Bron, France
showed that these changes were accompanied in changes in
oral and pharyngeal volumes. The aim of this study was to
Although many factors contribute to potential difficulties
evaluate intrapartum changes in MS in pregnant patients.
when intubating parturients, whether or not the maternal
Methods: After obtaining IRB and written informed consent,
airway is more difficult anatomically continues to be debat-
we studied airway changes in 24 healthy pregnant women
able. A previous study demonstrated that airway edema
who were admitted to the labor and delivery suite. Initial
can increase during the course of pregnancy and resulted
airway examination was graded during the 32-34th week
in an increase in Mallampati score (MS) (1). Acoustic reflect-
of pregnancy (T1) according to the Samsoon modification
ometry showed that these changes were accompanied in
of the Mallampati classification (SMM). The SMM was
changes in oral and pharyngeal volumes (2). Ultrasonog-
further measured before 4 cm of cervical dilation (T2), at
raphy has been evaluated for airway management in chil-
the end of the second stage of labor (T3) and 12-24h after
dren but has never been used in obstetric (3). The aim of
delivery (T4). Airway photographs were obtained using a
this study was to evaluate intrapartum changes in MS and
Canonw camera with parturient in the sitting position. A
in neck structures by ultrasound in pregnant patients.
senior anesthesiologist, who was blinded to the origin of
Methods: After getting IRB and written informed consent,
the photographs, analyzed and graded the airway into four
neck sonographic evaluation (Sonosite MicroMax, Sonosite,
classes. Parturient characteristics and fluids administered
Bothell, WA, with a linear 5–10 MHz probe) was carried out
during labor were recorded. Data were analyzed by using a
on 24 pregnant patients. Initial airway examination was
Chi-square test. Results are presented in table 1 (number
graded at admission in the labor room (T1) according to
patients). Mean age (SD) was 29+4 yr and weight
the Samsoon modification of the Mallampati classification
74+10 kg. Volume of fluids administered during labor was
(SMM: grade 1-4). The MS was further measured at the end
554+341 mL. Cervical dilation was 3+0.7 cm at T2 and
of the second stage of labor (T2) and 12-24h after delivery
9.3+0.8 cm at T3. There was a significant increase in SMM
(T3). Ultrasonographic measurements (USM) were performed
between T1 and labor (P,0.02) but there were no further sig-
at the same time. Three distances were measured: skin-vocal
nificant changes during labor and delivery.
cords (SVC), skin-thyroid isthm (STI) and skin-tongue base
Conclusion: Our finding showed that Mallampati score
(STB). Parturient characteristics and fluids administered
increases at the end of pregnancy but no further changes
during labor were recorded. Data were analyzed by using a
were noted during labor. This is in contrast with the study
ANOVA test.
of Kodali et al. (2) who observed a change in SMM during
Results: Mean age (SD) was 29+4 yr and weight 74+10 kg.
labor. The most likely explanation for this difference seems
Volume of fluids administered during labor was
to lie in different amounts of fluid given during labor (554
554+341 mL. Cervical dilation was 3+0.7 cm at T1 and
versus 2500 mL in Kodali study). A low fluid regimen policy
9.3+0.8 cm at T2. Labor and delivery have no significant
might provide better Mallampati scores during labor probably
effect on MS and on sonographic measurements (table 1).
by reducing neck edema.

Table 1

T1 T2 T3
SMM 12 34 STB (mm) 1,77+0,68 1,80+0,60 1,89+0,79
T1222 0 0 SVC (mm) 1,07+0,34 1,09+0,43 1,06+0,34
T21 2102 0 STI (mm) 1,09+0,34 1,07+0,36 0,99+0,24
T36 126 0 MS 1-2 (n) 22 18 19
T48 115 0 MS 3-4 (n) 2 6 5

ii200
Abstracts presented at WCA 2012
Conclusion: Our finding showed that Mallampati scores and
USM did not change during labor. This is in contrast with
the study of Kodali et al. (2) who observed a change in MS
during labor. The difference between the 2 studies in the
total amount of fluid given during labor seems to lie the
most likely explanation for our finding (554 versus 2500 mL
in Kodali study). A low fluid regimen policy might reduce
neck edema. Ultrasonography warrants further evaluation
as an adjunct to assessing the anatomy of the airway in
pregnant women.
References
1 Pilkingston S et al. Br J Anaesth 1995, 74: 638 –42
2 Kodali BS et al. Anesthesiology 2008; 108: 357 –62
3 Marciniak B et al. Anesth Analg 2009; 108: 461– 5
Paper No: 613.00
Comparison of intrathecal labor analgesia
using clinical doses of ropivacaine and
levobupivacaine
DuckHwan Choi, EunHee Kim and KyungMi Kim
Introduction: Intrathecal labor analgesia using newer local
anesthetics such as ropivacaine or levobupivacaine
becomes more popular due to their virtues of safety and
less motor weakness.
Objectives: To clarify efficacy differences of the clinical intra-
thecal doses of ropivacaine and levobupivacaine.
Methods: Sixty full-term parturients randomly received 3 mg
of intrathecal ropivacaine or levobupivacaine mixed with 20
mcg of fentanyl in their early active labor (30 patients in
each group), a part of combined spinal-epidural technique.
The associated block parameters, such as pain scores, dur-
ation of analgesia, and level of motor weakness, were inves-
tigated and compared between two groups. The primary and
secondary outcomes were duration of analgesia and inci-
dence of complete analgesia, respectively.
Results: Intrathecal ropivacaine offered shorter analgesia
(P¼0.02) with lower (sensory height P¼0.007) and it also
showed lower incidence of complete analgesia (P¼0.026)
than levobupivacaine. However, motor weakness on lower
extremities was comparable in both groups, but significantly
weak anal squeezing was noticed in the levobupivacaine
group (P¼0.03).
Conclusiona: Ropivacaine and levobupivacaine, 3 mg intra-
thecally administered with fentanyl, were both effective in
early labor analgesia. Levobupivacaine was more effective
in analgesic potency, but accompanied by a little motor
weakness.
BJA
Reference
1 Camorcia M, et al. Minimum local analgesic doses of ropivacaine,
levobupivacaine, and bupivacaine for intrathecal labor analgesia.
Anesthesiology. 2005; 102: 646–50.
Paper No: 665.00
The quality of CPR deteriorates during
transport in simulated maternal arrests
Jocelyn Wong 1, Steven Lipman 2, Sheila Cohen 3,
Julie Arafeh 4 and Brendan Carvalho 5
1
Dartmouth Medical School, Hanover, United States of America,
2
Stanford University School of Medicine, Stanford, 3 Stanford
University School of Medicine, Stanford, 4 Stanford University
School of Medicine, Stanford, 5 Stanford University School of
Medicine, Stanford
Introduction: The American Heart Association recommends
delivery within 5 minutes during an ongoing maternal
cardiac arrest (1,2). Many clinicians may transport arrested
patients to the operating room in order to perform a perimor-
tem cesarean delivery. The study objectives were to compare
the quality of cardiopulmonary resuscitation (CPR) rendered
by teams during transport versus while stationary.
Methods: We randomized 26 teams composed of two staff
(obstetricians, nurses, or anesthesiologists) to perform CPR
during transport or while stationary. We used a mannequin
(Laerdal Skills Reporter) designed to measure compressions
(rate, depth) and ventilations (rate, volume). Participants
practiced on the mannequin to perfect these skills prior to
the drill. Each drill was comprised of three phases: 4 min
while stationary, 2 min randomized to either remaining sta-
tionary or to transport, and 4 min while stationary. Transport
involved pushing the gurney with the manikin from the labor
room to the operating room. The primary outcome was
percent of correctly delivered compressions (based on
correct hand placement, depth.1.5 inches, correct body
position of the provider and proper release). Secondary out-
comes included several compression variables (rate, interrup-
tions, technique) and ventilation variables (tidal volume,
percent delivered correctly).
Results: The percent of compressions rendered correctly was
32% in the transport group and 93% in the stationary group
(P,0.001). The median (IQR) compression rates were 124
(110-140) and 123 (115-132) per minute in the transport
and stationary group respectively (P¼0.703). Median (IQR)
tidal volume was 270 (166-430) ml in the transport group
and 390 (232-513) ml in the stationary group (P¼0.031).
The percent of ventilations rendered correctly was 0% in
the transport group and 8% in the stationary group
(P¼0.048).
ii201
BJA
Conclusion: The quality of compressions and ventilations
decreased significantly during transport during simulated ob-
stetric cardiac arrest. Correct ventilations based on flow rate
and adequate (. 500 ml) volumes were challenging for both
groups perhaps because mask ventilation is more technical,
and the compliance of the mannequin was poor. Our data
suggests that in the event of a maternal arrest, transport
negatively impacts the quality of resuscitation. Previously
we showed that transport significantly delays perimortem
cesarean delivery. The current findings further strengthen
recommendations that perimortem cesarean delivery
should be performed at the site of arrest.
References
1 Katz V. Am J Obstet Gynecol 2005; 192: 1916–20.
2 American Heart Association, Circulation 2010; 122: S833– 38.
Paper No: 689.00
Anaesthetic management of a parturient
with mediastinal mass for caesarean
section
Choon Yee Lee, Azarinah Izaham and
Khairulamir Zainuddin
Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur,
Malaysia
Introduction: Patients with mediastinal masses are at risk for
cardiopulmonary complications, particularly under general
anaesthesia. The narrowed airway and obstruction to the
great vessels in the neck and thorax pose particular
dangers in the management of airway and the cardiovascu-
lar system.
Case Report: A 24 year old primigravida at 34 weeks gestation
was admitted to our Medical Centre with anterior cervical
mass and shortness of breath. She was referred to the anaes-
thesiologist and planned for urgent Caesarean section. Mag-
netic resonance imaging (MRI) examination revealed a soft
tissue mass with intrathoracic extension from the neck to
the level of trachea and carina, with evidence of airway com-
pression. The patient was admitted to the Intensive Care Unit
(ICU) one day prior to surgery. Her condition was stable with
oxygen supplementation via nasal cannula at 3 L/min, and
she was nursed propped up in bed.
We opted for low-dose sequential combined spinal-epidural
(CSE) anaesthesia as we considered it to be the safest anaes-
thetic technique. The otorhinolaryngologists were on standby
at the operating theatre in case emergency airway manage-
ment became necessary. The CSE block was performed at
L3-4 with the patient in the sitting position. Intrathecal injec-
tion consisted of 1.2 ml of 0.5% hyperbaric bupivacaine
(6 mg) and 15 mg fentanyl. A rapid bolus of 7 ml of saline
was injected via the epidural needle as per epidural volume
ii202
Abstracts presented at WCA 2012
expansion technique. The epidural catheter was inserted to
a depth of 5 cm in the epidural space and secured in place.
The patient was placed supine with 15o left lateral tilt and 30o
head elevation. Sensory loss to pinprick at T4 was achieved.
Surgery was allowed to commence. The patient required an
epidural top up with 2% lignocaine 5 ml during peritoneal in-
cision. After 15 minutes a baby with Apgar score 8/9 was deliv-
ered, and a slow intravenous bolus of oxytocin 5 units was
administered. Intraoperatively, her haemodynamic and re-
spiratory parameters remained stable throughout.
Multimodal postoperative analgesia was provided using
rectal diclofenac, epidural infusion of 0.1% levobupivacaine
with 2 mg/ml fentanyl, and oral etoricoxib on resumption of
oral intake. Epidural morphine was not used to avoid the
remote possibility of respiratory depression. The patient
was observed overnight in the ICU and discharged well to
the Medical High Dependency Ward the next morning for
further management.
Conclusion: Low-dose sequential CSE, with epidural volume
expansion, was successfully employed in a parturient with
mediastinal mass for Caesarean section.
References
1 Burlacu CL, Fitzpatrick C, Carey M. Anaesthesia for caesarean
section in a woman with lung cancer: case report and review.
Int J Obsteth Anesth 2007; 16: 50–62.
2 Crosby E. Anaesthesia for Caesarean section in a parturient with a
large intrathoracic tumour. Can J Anaesth 2001; 48: 575– 83.
Paper No: 719.00
What is the real anesthesic cost for a
Cesarian section in a Province hospital
from CHILE
Jorge Medina, Miguel Diaz and
Guillermo Quintanilla
Hospital del Huasco, Vallenar Chile
Introduction: Nowadays costs have become important in ad-
ministration of hospitals in all the country. Selfadministration
is new for province public hospitals.
Objectives: calculate the real anesthesis cost for a C section
Last year our maternaty had 668 C-sections.
Materials and Methods: a prospective study for 50 C-section
done starting from June 15 year 2011 was done. All C-section
were included; elective and emergency. Participants were the
three anesthesiologist that work in this hospital. Costs were
done for all variable anesthesia supplies and drugs for each
individual case.
Results: THE AVERAGE COST for the fifty cases was equivalent
to 12 US dollars
Discusion: FIFTY PERCENT of the anestesic cost is only by the
hyperbaric .75 buvivacaine and the spinal trocar.
Abstracts presented at WCA 2012
Conclusions: costs for C-section anesthesia change depend-
ing of the number of bupivacaine vial and number of spinal
trocar. It is posible to improve anesthesia cost administration
for the maternity.
Reference
1 Programa de intervencion clinica y economica de la operacion
cesarea en el Hospital Clinico de la Universidad de Chile.
REVCHIL oBSTET ginecol 2002; 67(6): 451– 455.
Paper No: 720.00
Anesthesia in pregnant myasthenic
Idoris Cordero
Introduction: Myasthenia gravis (MG) is an autoimmune
disease characterized by circulating antibodies of the type
of immunoglobulin G (IgG), which interact with cholinergic
receptors and interfere with the mechanism of neuromuscu-
lar transmission.
Objectives: To describe the behavior of pregnant women
perioperative with myasthenia gravis. Features of pregnancy:
The course of MG during pregnancy is unpredictable. The
worsening picture can occur between the first and third
quarter. When a myasthenic, are pregnant should consult
your obstetrician and inform your base doctor as soon as is
confirmed. In these patients, premature birth is common.
Anticholinesterases can cause uterine contractions. Stress
implies increased myasthenic crisis. The occurrence of pre-
eclampsia associated MG is uncommon, but when occurs
can be catastrophic for both mother and fetus.
Perioperative Practice: These patients may present greater
interference in labor and the postpartum period, so it
requires a real team.
Anesthetic Considerations: Monitoring should be complete
including neuromuscular function. It attaches great import-
ance to the mode of delivery, but it is widely accepted that
the myasthenic they should perform elective caesarean
section and only when there are obstetric reasons only.
Some prefer regional anesthesia (epidural), but others
prefer general anesthesia.
Medical Treatment: The anticholinesterases, are the treat-
ment of choice, as well as steroids and immunosuppressive
drugs. Plasmapheresis is deprecated. Hyperimmune globulin
intravenous (Intacglobin) has been used successfully. Should
not be given magnesium sulfate.
Considerations: Breastfeeding your child for a myasthenic
woman is always possible to take into account the severity
of symptoms.
Peculiarities of the newborn: Some newborns may have
neonatal myasthenia, temporary condition of general weak-
ness in the newborn whose mother has MG. Its incidence
ranges from 12 to 20 % and not all children of the same
mother, presented a neonatal MG.
BJA
Conclusions: Myasthenia gravis is associated with increased
complications. There is an increased risk of preterm labor,
premature rupture of membranes, the greater potential of
interventions and perinatal morbidity and mortality, so that
the conduct of anesthesia should be accurate to prevent
morbidity and mortality from this cause.
Paper No: 788.00
Labor epidural analgesia in an operated
patient of syringomyelia with arnold chiari
type 1 malformation: a rare case report
Nallasivam Natarajan and Sherin Joseph
Medcare Hospital, Dubai, Uae
Introduction: Arnold Chiari1 malformation consists of elong-
ation of the cerebellar tonsils with their displacement below
the foramen magnum. Syringomyelia is an associated cystic
formation in the spinal cord due to disturbed mechanism of
cerebrospinal fluid flow, resulting in a degenerative neur-
opathy. In a labouring woman this condition poses concern
because of the potential risk of neurological deterioration
as a result of the physiological changes and the interventions
during labour and delivery.
Epidural analgesia could be beneficial in abolishing pain and
thereby the increase in intracranial pressure but at the same
time the procedure in itself could aggravate the neurological
symptoms. We report the successful management of a
normal vaginal delivery under epidural analgesia in a
woman with a surgically corrected Arnold Chiari type 1 mal-
formation with syringomyelia and scoliosis. Case Report 26
year old primiparous woman presented in early labour. She
had undergone a therapeutic subdural shunt surgery for AC1
malformation with cervicothoracic (up to T11) syringomyelia
six years previously. She had minimal residual neurological
symptoms like reduced sensation to pain and temperature
from T12-L2 and occasional paresthesia of upper limbs. The
symptoms were more pronounced on the right side but no ag-
gravation during the pregnancy. She had an associated thor-
acic scoliosis and right upper limb atrophy. X-ray was done
post delivery showing scoliosis with intra thecal shunt at thor-
acic vertebra level. Upon request from the patient for pain
relief Epidural analgesia was planned after detailed discussion
with the neurologist and obstetrician. Epidural catheter was
placed in. L-3-4. . ...level under aseptic precautions. Analgesia
was initiated with a titrated bolus dose of 10 ml of 0.0625%
bupivacaine +50 mg fentanyl and was continued until delivery
with 6ml /hour of 0.125% bupivacaine +2 m/ml fentanyl. She
had an uneventful vacuum assisted vaginal delivery. The
patient was reviewed 2 weeks latter by the neurologist with
a MRI spine and a detailed examination revealed the same
neurological findings before going for the labour epidural.
MRI: shows right syringo-hydromyelia along the cervical and
upper dorsal spinal cord.
ii203
BJA
Discussion: Syringomyelia is a rare progressive degenerative
neuropathy characterised by cystic formation within the
spinal cord with accumulation of cerebrospinal fluid that
can impinge on nerve fibres resulting in neurological mani-
festations. The congenital form commonly is associated
with Arnold-Chiari 1 malformation and occurs in the cervi-
cothoracic level.
The preferred mode of delivery and anaesthesia in a parturi-
ent with syringomyelia is controversial. The prime concern is
avoidance of straining and thus fluctuation in the intracranial
pressure during the labour and delivery. Only few reports of
successful vaginal delivery under epidural analgesia are
present.
The major concerns during epidural anaesthesia in such
patients are: 1) Further neurological deterioration 2) Tech-
nical difficulties especially due to the presence of spine ab-
normalities like scoliosis 3) Increased risk of dural puncture
4) Abnormalities of autonomic nervous system can cause
exaggerated cardiovascular instability 5) Unpredictability of
the level of sensory blockade.
Conclusion: The use of Epidural analgesia for parturient with
Neurological conditions like Arnold chiari malformation with
syringomyelia is controversial; we would like to highlight that
a meticulously done low dose epidural analgesia is still an
option considering the benefits in such patients.
References
1 Sicuranza, Genevieve B, Steinberg P, Figueroa R. Arnold-Chiari mal-
formation in a pregnant woman. Obs and gynec 2003; 102(5):
1191– 4.
2 Nawaz Y, McAtamney. Anaesthetic management of Caesarean
section in a patient with syringomyelia. The Internet J of Anaesthe-
siology 2011; 28:No:2.
3 Parker JD, Broberg JC, Napolitano PG. Maternal Arnold –Chiari type
I malformation and syringomyelia: a labor management dilemma.
Am J Perinatol.2002; 19(8): 445– 50.
4 Jayaraman L, Sethi N, Sood J. Anaesthesia for caesarean section in
a patient with lumbar syringomyelia. Reb Bras Anestesiol 2011;
61(4): 469–73.
5 Agusti M, Adalia R, Fernandez C, Gomar C. Anaesthesia for caesar-
ean section in a patient with syringomyelia and Arnold-Chiari mal-
formation. IJOA 2004; 13(2): 114– 6.
Paper No: 797.00
Risk factors for massive hemorrhage during
cesarean section in patients with placenta
previa
Mizuko Ikeda, Rika Esaki, Noriko Nanishi,
Kozaburo Akiyoshi and Ken Yamaura
Kyushu University Hospital
Introduction: Placenta previa (PP) is one of the major causes
of massive obstetric hemorrhage. Well known risk factors for
bleeding in PP are old age, previous cesarean section (CS),
ii204
Abstracts presented at WCA 2012
increased BMI, increased neonatal weight, complete previa
and especially the presence of placental accrete. In addition,
it has been reported that general anesthesia (GA) is an inde-
pendent risk factor for massive bleeding (MB) in PP patients.
Objectives The purpose of this study was to elucidate the risk
factors contributing to the incidence of MB in PP patients. We
also investigated the factors associated with the choice of
anesthetic method.
Methods: We retrospectively reviewed all women with PP
who underwent CS during September 2006 to August 2011
at Kyushu University Hospital. The following factors were
extracted from medical records: age, BMI, gestation,
number of previous CS, emergency or elective, the anesthetic
technique used (GA/RA) and the estimated blood loss (EBL)
during surgery. Ultrasound findings within a week before CS
were available in most patients; type of PP (marginal/com-
plete), placental location (anterior/posterior) and the pres-
ence of placental accrete were also included in the
analysis. Multivariate logistic regression was performed to
determine independent risk factors for MB (¡Ý2500ml) and
to investigate factors associated with the choice of anesthet-
ic method. For statistical tests, P,0.05 was considered
significant.
Results: Among 109 patients, median EBL was 1,340ml
(range 270?11,348). There were 16 cases of MB. Emergency
surgery (OR; 3.8, 95%CI; 1.1?13.0) and anterior placental lo-
cation (OR; 4.2, 1.2?15.3) were found to be independent risk
factors for MB. Overall, regional anesthesia was employed
for most cases, 89% (97/109). Two of these women were
later converted to GA because of the excessive hemorrhage.
Anesthesiologists employed GA when a patient had a history
of CS (OR; 7.1, 1.1?43.8) and in case of emergency (OR; 14.9,
2.1?108.5). Median EBL during surgery with RA and GA were
1,292ml (270?10,800) and 2,795 ml (429?11,348), respective-
ly (P ,0.05).
Conclusions: Emergency surgery and location of placenta are
risk factors for MB during CS in cases of PP regardless of
whether placental accrete is present. Anesthesiologists
seemed to choose GA depending on a history of CS, which
was associated with MB well. Additional information of sono-
graphic exam on the placental position before the uterine in-
cision may help anesthesiologists to develop a strategy to
manage patients with PP.
References
1 Parekh N, Husaini SW, Russell IF. Caesarean section for placenta
praevia: a retrospective study of anaesthetic management.
British journal of anaesthesia 84, 725– 30 (2000).
2 Hasegawa J et al. Predisposing factors for massive hemorrhage
during Cesarean section in patients with placenta previa. Ultra-
sound in obstetrics & gynecology: the official journal of the Inter-
national Society of Ultrasound in Obstetrics and Gynecology 34,
80 –4 (2009).
3 Frederiksen MC, Glassenberg R, Stika CS. Placenta previa: a 22-year
analysis. American journal of obstetrics and gynecology 180,
1432– 7 (1999).
Abstracts presented at WCA 2012
4 Clinical S, Guideline P. Diagnosis and Management of Placenta
Previa. Magnetic Resonance Imaging 261– 266 (2007).
Paper No: 804.00
Quality assessement of the practice of
obstetrical anaesthesia at muhima
district hospital
Paulin Ruhato 1, Theogene Twugirumugabe 1 and
Hafez Sami 2
1
Faculty of Medicine, National University of Rwanda. 2 DuPage
Valley Anesthesiologists, Naperville, IL, USA.
Objectives: The quality of anesthesia is a main determinant
of maternal and neonatal outcomes in obstetrics (1). We
set out to describe the quality of obstetrical anesthesia at
Muhima district hospital in Rwanda and its possible effects
on maternal outcomes.
Methods: This was a prospective observational study of con-
secutive caesarean sections performed at Muhima District
Hospital in Kigali, Rwanda over a period of 4-months, from
February 1st to May 31st, 2009. Muhima is a single-specialty
hospital dedicated to obstetrics and gynecology. The data
was collected from a 6 category-item survey questionnaire:
admission parameters, labor progress record, anesthesia
record, postoperative record, discharge criteria and neonatal
status. The data were analyzed with descriptive and inferen-
tial statistics and regression analysis at the 95% confidence
level.
Results: Data from 602 consecutive patients were analyzed.
According to the admitting physicians’s classification,
17.4% were emergent, 2.2 % urgent, 74.1% semi-urgent
and 6.3% were scheduled. Preanesthetic assessment was
not done in 95% of patients. Thirteen patients (2.2%) had
general anesthesia as the primary anesthetic, 11 of whom
(84%) were not intubated. The decision to delivery Interval
(DDI) was consistently greather than 30 minutes in all
groups. Mothers in the urgent group had a higher frequency
of complications and were more likely to receive general an-
esthesia. Their DDIs were the shortest among the groups.
There was a high incidence of failed spinals (7.2%) all of
which were converted to general anesthesia without intub-
ation. Post-operative analgesia consisted solely of diclofenac.
Overall mortality for caesarean sections was 500/100,000.
Conclusion: Our findings point to substandard anesthetic
management of caesarean sections (2). Namely, the
absence of pre-anesthetic evaluation (3), prolonged DDI (4),
a predominance of general anesthesia without a protected
airway (3), and a high incidence of failed regional anesthesia.
The most alarming finding is that of a maternal mortality of
500/100,000 compared with 2/million in the United States
(1), a differential of 2,500 times. The latter is far greater
than that for combined modes of delivery of 100-200 times
(5). Further studies are needed to explore the causes of
such a high differential.
BJA
References
1 Hawkins JL, Koonin LM, Palmer SK, Gibbs CP. Anesthesia-related
deaths during obstetric delivery in United States. 1979–1990. An-
esthesiology 1997; 86: 277– 84.
2 Organisation mondiale de la santé. Classification internationale
des maladies et problèmes de santé connexe.10e révision.
Genève : OMS 2005.
3 Roanne Preston: Challenges in obstetric anesthesia and
analgesia, CAN J ANESTH 55: 6 www.cja-jca.org
June, 2008
4 De Regt RH, Marks K, Joseph DL, Malmgren JA. Time from decision
to incision for cesarean deliveries at a community hospital. Obstet
Gynecol 2009; 113: 625– 9.
5 Office Nationale de la Population (ONAPO) [Rwanda] et ORC
Macro. 2001. Enquête Démographique et Santé, Rwanda 2000.
p. 188
Paper No: 825.00
Anaesthetic Management for Successive
Spinal Cord Surgeries During Pregnancy
and Postpartum
Demet Coskun, Ahmet Mahli, Ulku Emik,
Rabia Ozdemir and Hakan Emmez
Gazi University Faculty of Medicine / Department of
Anaesthesiology and Reanimation
Objectives: Treatment strategy of spinal cord lesions requires
consideration of multiple factors including location of the
spinal cord compression, presence of spinal deformity,
speed of neurologic decline, stage of pregnancy and poten-
tial risks to the foetus. Since the anaesthetic management
of these patients according to stage of pregnancy is import-
ant, we present the anaesthetic management of a parturient
with spinal tumour.
Case Report: A 25- year old woman, gravida 1, para 0, at 28
weeks? gestation with a 4-day history of bilateral lower limb
weakness and altered sensation was admitted to our institu-
tion. Emergency magnetic resonance imaging (MRI) of the
dorsal spine was requested. The MRI results revealed a
lesion at the entire of T8-9 thoracic vertebra with involve-
ment of the posterior elements, osseous extension into the
extradural space and paravertebral soft tissue. She was ur-
gently admitted to the neurosurgery department to
undergo laminectomy and decompression by the 303
weeks of her gestation. After invasive blood pressure, periph-
eral oxygen saturation and fetal heart rate (FHR) monitoriza-
tion, anaesthesia was induced using propofol, rocuronium
bromide followed by total intravenous anaesthesia with pro-
pofol and remifentanil. During the operation, haemodynam-
ics, central venous pressure, peripheral oxygen saturation,
acid base status and FHR were stable. After skin incision;
total laminectomy of T8-T9, posterior decompression and
subtotal excision of the lesion were performed. Following
extubation, she was taken to post anaesthesia care unit
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and then obstetric ward. Two weeks after her operation, at
32 weeks? gestation, she underwent caesarean section
under general anaesthesia. Four weeks later, the patient
was electively prepared for a total neurosurgical excision of
the lesion.
Conclusion: The etiopathogenesis, clinical and radiological
features, and treatment modalities of an uncommon cause
of thoracic spinal cord compression associated with preg-
nancy were addressed in this case report. Physiologic
changes during pregnancy may lead to acute spinal cord
compression due to tumour growth and expansion. Failure
to recognize the lesion and delayed treatment can lead to
potentially serious complications. We believe that our anaes-
thetic management allows us to perform this surgical pro-
cedure with maximal maternal and fetal safety.
References
1 Han I et al. Spine 2008; 33: 614– 9.
2 Ni Mhuireachtaigh R, O?Gorman DA. J Clin Anesth 2006; 18: 60 –6.
Paper No: 854.00
Loss of resistance to air versus saline
technique in epidural anesthesia for labor:
a randomized, prospective study
Genaro Maggi, Nicolas Brogly, Renato Schiraldi,
Laura Puertas and Emilia Guasch
Introduction: Loss to air technique in epidural analgesia for
labor is a controversial approach due to increased rates of
failures and complications, when compared to loss to
saline technique (1-3). In this randomized, prospective
study we compared the efficacy and the rate of complica-
tions employing the two techniques.
Materials and Methods: After obtaining Ethical Committee
approval and written consent from patients, 400 parturient
were allocated, using sealed envelopes, to receive epidural
analgesia either using the loss to air (group 1) or the loss
to saline (group 2) technique. Level of efficacy of the anal-
gesia was monitored after 30 minutes and during expulsion
of the fetus by an appropriate scale ranking 0-3 (0¼no
pain; 3¼total failure of analgesia). 24 hours after delivery,
pain in the site of epidural puncture and maternal satisfac-
tion were evaluated, using a 0-10 scale. There were 177
patients in each group, considering a difference of 20% in
the block efficacy (á¼0,05, â¼0,1). ANOVA was employed
for parametric data and Chi-2 for non-parametric data. A p
value,0,05 was considered significant.
Results: 11 patients in each group were excluded from the
study for protocol violation. No difference in analgesia effi-
cacy was reported at 30 minutes (1,03+0,65 in group 1 vs.
1,03+0,66 in group 2; p¼1,00), nor during fetus expulsion
(0,72+0,71 vs. 0,69+0,63; p¼0,67). Complications during
technique were reported in 38 patients in group 1
ii206
Abstracts presented at WCA 2012
(20,6%) vs. 39 patients in group 2 (21,1%; p¼0,50). Dural
puncture was recorded in 2 patients in group 1. During
labor, lateralization of analgesia was reported in 26
patients in group 1 (13,7%) vs. 16 patients in group 2
(8,5%; p¼0,08). Inefficacy of analgesia needing a new epi-
dural puncture was reported in 16 patients in group 1
(8,5%) vs. 7 patients in group 2 (3,7%; p¼0,03). 24 hours
after delivery, 84 patients in group 1 (44,4%) referred
pain in the site of the epidural puncture, vs. 65 patients
in group 2 (34,4%; p¼0,02). On the other hand, there
was no difference between groups about maternal satis-
faction (8,35+2,66 vs. 8,58+2,68; p¼0,42).
Conclusions: In the present study, epidural puncture tech-
nique didn’t seem to compromise analgesia efficacy or to
induce more complications. However, when loss of resistance
to air technique was employed, lateralization of the anal-
gesic block and re-puncture were more frequent. Moreover,
this technique was associated to an increased rate of pain
in the site of the epidural puncture, although maternal satis-
faction was not impaired.
References
1 Grondin LS, et al. Success of spinal and epidural labor analgesia:
comparison of loss of resistance technique using air versus
saline in combined spinal-epidural labor analgesia technique. An-
esthesiology 2009; 111(1): 165– 72.
2 Schier R, et al. Epidural space identification: a meta-analysis of
complications after air versus liquid as the medium for loss of re-
sistance. Anesth Analg 2009; 109(6): 2012–21.
3 Segal S, Arendt KW. A retrospective effectiveness study of loss of
resistance to air or saline for identification of the epidural space.
Anesth Analg 2010; 110(2): 558–63.
Paper No: 898.00
Needs assessment to achieve Millennium
Development Goal 5 defined by staff at
Mbarara University Hospital Uganda
Rosel Tallach 1, Joseph Ngonzi 2, Joseph Kiwanuka 2,
Stephen Ttendo 2 and Paul Howell 3
1
Royal London Hospital, London, UK, 2 Mbarara Regional Referral
Hospital, Uganda, 3 Homerton University Hospital, London, UK
Introduction: The aim of MDG5 is to reduce the 1990 mater-
nal mortality ratio (MMR) by three-quarters in 2015 (1). Ma-
ternal deaths are largely avoidable with appropriate
antenatal and peripartum care. Interventions to reduce ma-
ternal deaths are well described, but there has been limited
progress in sub-Saharan Africa in recent years (2). The
Uganda Ministry of Health reported a MMR of 430 per 100
000 live births in 2008, equivalent to 1 in 25 lifetime risk of
maternal death (3).
Quality improvement methods may be effective in low-
income settings (4,5). A preliminary needs assessment
Abstracts presented at WCA 2012
involving key stakeholders is required and may point to
factors than can be generalized to similar settings.
Objectives: To perform structured interviews to ascertain opi-
nions of healthcare workers regarding provision of obstetric
care in a regional referral hospital, changes required and bar-
riers to improvement.
Methods: Structured interviews were conducted with obste-
tricians, anaesthetists, clinical officers, and midwives at
Mbarara Regional Referral Hospital, Uganda during one
week in June 2010. Ethics approval was obtained. Open
questions were asked and answers were not prompted. An
independent anaesthetist reviewed interview transcripts for
recurring themes.
Results: Interviews were conducted with nine members of
staff, each lasting between 20-40 minutes. Representatives
of all grades of anaesthetist, obstetrician and midwife were
interviewed. Three recurring themes emerged:
(1) Lack of nursing staff (9/9 interviewees) “In the
daytime there are enough staff, but at night we
have only two nurses for up to 90 patients” Senior
midwife “There have been patients who have deterio-
rated and no one knew.“ Obstetric intern.
(2) Lack of material resources (7/9 interviewees) “When
the budget runs out we have to send patient relatives
out to buy sutures, cannulae, giving sets ” Obstetric
consultant “We could not operate for a whole month
because we didn’t have gloves or oxygen” Obstetric
consultant
(3) Lack of training courses (6/9 interviewees) “We have
not received any training in how to recognize a critic-
ally ill mother. I would like us to have this instead of
finding them when they are too ill to save” Obstetric
intern
Conclusions: These interviews have identified factors that
need to be addressed to improve maternal outcomes in
this setting – support for nursing staff, particularly at night,
improved resources, and improved training, particularly in
recognition of the critically ill mother. They reflect findings
previously identified in this setting (6) and will be used to
direct a quality improvement programme in the hospital.
References
1 United Nations. End poverty 2015. Millennium Development Goals
http://www.un.org/millenniumgoals/maternal.shtml (accessed 3rd
September 2011)
2 WHO Making Pregnancy Safer. http://www.afro.who.int/en/
clusters-a-programmes/frh/making-pregnancy-safer.html. (access
ed 3rd September 2012)
3 WHO. Global Health Observatory Data Repository http://apps.-
who.int/ghodata/?vid¼20300&theme¼country (accessed 3rd Sep-
tember 2011)
4 Kotagal M, Lee P, Habiyakare C, et al. Improving quality in resource
poor settings: observational study from rural Rawanda. BMJ 2009;
339: 1311–1313
5 Engmann C, Olufolabi A, Srofenyoh E. Multidisciplinary Team Part-
nership to Improve Maternal and Neonatal Outcomes: The Kybele
BJA
Experience. International Anaesthesiology Clinics 2010; 48 (2):
109–122
6 Hodges SC, Mijumbi C, Okello M et al. Anaesthesia services in devel-
oping countries: defining the problems. Anaesthesia 2007 62:
4 –11
Paper No: 900.00
Anaesthesia for Caesarean Section
in Palestine
Hadeel Gheith 1, Hassan Ismael 1 and
Haydn Perndt 2
1
Makassed Hospital, Jerusalem, West Bank, Palestine, 2 Royal
Hobart Hospital, Hobard, Tasmania, Australia
Introduction: Spinal anaesthesia is now considered the
method of choice for both urgent and elective Caesarean
section 1 The use of general anesthesia has fallen dramatic-
ally in the past few decades and accounts for only 5% of Cae-
sarean sections in the United States2. In our hospital, the
Al-Makassed Islamic Charitable hospital, a teaching and ter-
tiary referral hospital for Palestine, the proportions are
almost completely reversed. This reflects practice in the
other Palestinian hospitals of the West Bank.
Objectives: The aim of this study was to review anesthesia
practice for Caesarean section in the Makassed hospital.
We sought to establish the data for the incidence of
general anaesthesia and spinal or epidural anaesthesia for
Caesarean section in 2010. In addition we sought an explan-
ation for this incidence. And finally we wanted to know
whether there were reasons to change the contemporary
practice of anaesthesia for Caesarean section in Palestine.
Methods: This is a retrospective observational study. We
reviewed the files of all patients who underwent Caesarean
delivery in the period from 1st of Jan - 31st Dec 2010 at
the Al-Makassed hospital. Both Emergency and Elective
cases were included. We recorded the following: age and
parity of the mother, type of anaesthesia given, indication
for the caesarean, 1-minute and 5-minutes APGAR scores
of the baby, regional block proceduralist. SPSS software was
used to analyze the data.
Results: In 2010 we found that there were 647 cases of Cae-
sarean deliveries out of 2764 total deliveries 23.4 %. Of the
caesareans: 50.5% were emergency cases and 49.5% were
elective cases. Of the emergency cases: 78 % given general
anaesthesia, 16.5% were spinal, 3.4% epidural and
2.1%failed spinal converted to general anaesthesia.
Whereas for the elective cases : 71.6% given general anaes-
thesia, 24.4% spinal, 0.6% epidural, 3.1% failed spinal, 0.3%
combined spinal epidural. Totally 2.6% of the spinal anaes-
thesia failed and were converted to GA. There were no
other significant complications attributed to spinal anaesthe-
sia. There was no incidence of airway difficulty or aspiration
following general anaesthesia. There is single case who
ii207
BJA
died 3 hours post ceasarean with a clinical diagnosis of
massive Pulmonary embolism.
Conclusions: Although our numbers are relatively small,
general anaesthesia appears to be safe in our hands. Any
change in obstetric anaesthesia practice in Palestine would
have to confront deeply held historical Obstetric beliefs and
well entrenched cultural traditions in our patient population.
With maternal mortality associated with general anaesthesia
at 6.5 per million and that of regional anaesthesia at 3.8 per
million in the US2, would a change in practice make any sig-
nificant difference to anaesthetic morbidity and mortality in
Palestine? What are the implications for other low and
middle income countries in “Anaesthetic transition”?
References
1 Best practice and research. Clinical anaesthesiology. 2003 Sep;
17(3): 377–92
2 Bucklin BA, Hawkins JL, Anderson JR, Ullrich FA. Obstetric anesthe-
sia workforce survey: twenty-year update. Anesthesiology 2005;
103: 645s
3 Up To Date: anesthesia for caesarean deliveries. Topic updated May
9, 2011. Editor Hepner David L http://www.uptodate.com/contents/
anesthesia-for-cesarean delivery 4 Centre for Maternal and Child
Enquiries (CMACE). Saving Mothers Lives: reviewing maternal
deaths to make motherhood safer: 2006-2008. The Eighth
Report on Confidential Enquiries into Maternal Deaths in the
United Kingdom. BJOG 2011; 118 (Suppl. 1), 1– 203
Paper No: 930.00
Relationship between the administration
of preincisional intravenous fentanyl in
patients under cesarean section with
epidural anesthesia and the apgar score
of newborns. hospital nacional Daniel
A. Carrión – 2011
Freddy Espinoza
Introduction: Although the sedoanalgesia is used in the op-
erating room to relieve the stress of the patient undergoing
surgery under regional anesthesia, many anesthesiologists
are reluctant to use it in cesarean section by fear of the po-
tential effects that drugs can have on the fetus.(1) Even
though there is evidence that fentanyl is safe in pregnant
women when it is used for labor analgesia, studies are incon-
clusive when it is used as an adjunct to cesarean section
under regional anesthesia (2).
Objectives: Determine if exists relationship between the pre-
incisional intravenous fentanyl administered to patients
under cesarean section with epidural anesthesia and the
Apgar scores of newborns.
Material and methods: Observational, analytical, prospective
and longitudinal study in pregnant women undergoing
ii208
Abstracts presented at WCA 2012
cesarean section at Hospital Nacional Daniel A. Carrión in
2011. 64 patients were included, 32 receiving, at the judg-
ment of the responsible anesthesiologist, intravenous fen-
tanyl before surgical incision (GF) and 32 who did not
receive any sedoanalgesia (GC). We recorded the Apgar
score of the newborn at one minute and 5 minutes. For the
analysis of the data was used the Mann Whitney test.
Results: The dose of fentanyl administered was 1.48+0.04
?g.kg-1. There was no statistically significant difference
between groups in the Apgar score at one minute (GF 8.81
[8-9], GC 8.81 [7-9], p¼0.886) or 5 minutes (8.97 GF [8-9],
GC 9.6 [9 - 10], p¼0.085).
Discussion: The possibility of side effects of fentanyl on the
product is in relation to the amount that crosses the placen-
tal barrier and reaches the fetal circulation, with an esti-
mated minimal plasma concentration to produce
respiratory depression in the neonate of about
2 ng.m-1.(3,4) Experimental and clinical evidence indicate
that very little amount passes from mother to fetus and
that the relationship between maternal and fetal plasma
levels is greater than 2.5.(5-7) Although maternal plasma
concentration was not measured in this study allowing calcu-
lation the fetal concentration, studies using fentanyl macro-
dosis for major surgery in neonates showed that it requires
25 to 50 ?g.kg-1 to achieve plasma concentrations of
3.8 ng.ml-1.(8) It could be argued that the dose of 1.48
?g.kg-1 used in this study as sedoanalgesia would be insuffi-
cient to reach toxic levels for the newborn.
Conclusions: We found no evidence that fentanyl intravenous
at doses of 1.48 mg.kg-1 administered before the surgical in-
cision in cesarean section have deleterious effects on the
newborn.
References
1 Mattingly JE, D’Alessio J, Ramanathan J. Effects of obstetric
analgesics and anesthetics on the neonate: a review. Pediatr
Drugs. 2003; 5: 615– 27.
2 Frölich MA, Burchfield DJ, Euliano TY, Caton D. A single dose of fen-
tanyl and midazolam prior to Cesarean section have no adverse
neonatal effects. Can J Anesth. 2006; 53: 79 –85.
3 Cartwright P, Prys-Roberts C, Gill K, et al. Ventilatory depression
relate to plasma fentanyl concentrations during and after anes-
thesia in humans. Anesth Analg. 1983; 62: 966–74.
4 Stoeckel H, Schuttler J, Magnussen H, Hengstmann J. Plasma fen-
tanyl concentrations and the occurrence of respiratory depression
in volunteers. Br J Anesth. 1982; 54: 1087–95.
5 Craft J, Coaldrake L, Bolan J, et al. Placental passage and uterine
effects of fentanyl. Anesth Analg. 1983; 62: 894– 8.
6 Rosaeg O, Kitts J, Koren G, Byford L. Maternal and fetal effects of
intravenous patient-controlled fentanyl analgesia during labour
in a thrombocytopenic parturient. Can J Anaesth. 1992; 39:
277–81.
7 Eisele J, Wright R, Rogge P. Newborn and maternal fentanyl levels
at cesarean section. Anesth Analg. 1982; 61: 179– 80.
8 Koehntop D, Rodman J, Brundage D, et al. Pharmacokinetics of
fantanyl in neonates. Anesth Analg. 1986; 65: 227–32.
Abstracts presented at WCA 2012
Paper No: 998.00
Development of a ’lay mews’ for patient
attendants in the obstetric wards in
Mbarara Regional Referral Hospital Uganda
Isabeau Walker 1, Nicki Ross 2, Joseph Kiwanuka 3,
Joseph Ngonzi 3 and Ivan Wong 4
1
Great Ormond Street Hospital NHS Trust, London, UK, 2 Leeds
Teaching Hospitals NHS Trust, Leeds, UK, 3 Mbarara University
Teaching Hospital, Mbarara, 4 North West London Hospitals NHS
Trust, London, UK
Introduction: Common causes of maternal death are haem-
orrhage, sepsis, eclampsia and obstructed labour. Maternal
collapse usually precedes cardiac arrest and outcomes are
improved by recognising the sick mother (1). The Modified
Early Warning Score (MEWS) has been validated as a predict-
or of mortality (2,3,4). The eighth report of the UK Confiden-
tial Enquiries into Maternal Deaths recommended routine
use of an obstetric MEWS to help in the recognition, treat-
ment and referral of women who have developed or are
developing critical illness (5).
Uganda has shown slow progress towards achieving MDG 5,
in common with many countries in sub-Saharan Africa.
There are around 8,000 deliveries pa at Mbarara University
Hospital, and in 2009 there were .50 maternal deaths. A
needs assessment identified a severe shortage of nursing
staff on the wards as one of the factors to be addressed.
At night, two nurses look after labour, antenatal and post-
natal wards, making it difficult to undertake routine observa-
tions to identify deteriorating patients. However, every
patient receives basic care from an attendant, usually a
family member, who may be an underutilized resource.
Objectives: To develop an objective tool for use by patient
attendants to alert nurses to a deteriorating patient requiring
formal assessment.
Methods: Consensus views of five UK consultant obstetric
anaesthetists identified key warning signs relating to the de-
teriorating mother. An obstetrician and six senior midwives
in Mbarara were interviewed to assess the feasibility of a
‘lay MEWS’. The educational background of patients was
assessed. Patient attendants in Mbarara were interviewed
to assess their understanding (data collection on-going).
Results: Consensus views identified five key warning signs:
† Bleeding
† Fast breathing
† Behaving strangely or having a fit
† Headache
† Patient feeling cold
One in four patients in Mbarara are peasant farmers, there is
a low rate of literacy, and a written instruction chart was not
deemed feasible. A pictorial chart was developed and trans-
lated into local languages, Lugandan and Runyankol. The
final lay MEWS is shown (Figure).
BJA
Conclusions: In Mbarara University Hospital Obstetrics De-
partment, the patient attendant may be an underutilized re-
source and may compensate for nursing shortages. Based on
expert advice and consensus, we have devised a pictorial
chart with local language translation as a novel and feasible
method for training attendants to identify five clinical signs
of deterioration. This chart may have wider applications in
other resource-limited settings. Impact on patient outcomes
in Mbarara will be assessed after implementation.
References
1 King SE, Gabbott DA. Maternal cardiac arrest – rarely occurs, rarely
researched. Resuscitation 2011 82: 795– 96
2 Subbe CP, Kruger M Rutherford et al. Validation of a modified Early
Warning Score in medical admissions QJM 2001 94: 521– 26
3 Gardner-Thorpe J, Love N, Wrightson J et al. Ann Roy Coll Surg Eng
2006 88: 571– 75
4 Bleyer AJ, Vidya S, Russell GB et al. Longitudinal analysis of one
million vital signs in patients in an academic medical center. Re-
suscitation 2011: doi:10.1016/j.resuscitation.2011.06.033
5 Centre for Maternal and Child Enquiries. Special Issue: Saving
Mothers’ Lives: Reviewing maternal deaths to make motherhood
safer: 2006– 2008. The Eighth Report of the Confidential Enquiries
into Maternal Deaths in the United Kingdom BJOG 2011: 118 1– 203
Paper No: 1012.0
Post cesarean section pain in the west bank
Ahmed F M Awad
Introduction: In December 2007, the Center for Disease
Control and Prevention (CDC) reported that caesarean
section (CS) rate in the developed world varied between
33.3% in Italy and 12.9% in the Netherlands (1). In Rafidia
Surgical Hospital in Nablus, the CS rate was about 11% in
the 1970s and increased to 14% in the 1990s. During the
Al Aqsa uprising in 2000- 2004 this percentage remained
the same until the incursion of Nablus city in 2002, after
which the CS rate increased to 21%. The explanation for
this sudden change was that parturients at term demanded
cesarean delivery because they were very concerned about
inevitable delays at check points in the West Bank.
Objectives: The main objective of this study was to evaluate
several factors influencing the intensity of postoperative pain
in women undergoing CS. These factors included family
issues, nursing staff behaviours, length of procedure, socio-
economic status of the patients, anti-natal care, previous ex-
perience of surgical pain and post-operative complications.
Methods: This study was conducted during the period from
February –March 2011 and carried out in 3 government hos-
pitals in the cities of Nablus, Jenin and Ramallah. A patient
questionnaire was generated and a survey was conducted,
using face to face interviews and additional information
was obtained from the patients’ files.
Results: Three hundred and twenty eight women undergoing
general anesthesia for CS agreed to participate in this
ii209
BJA
prospective, multicenter, survey. Patients were interviewed
pre-operatively on the day of surgery and informed consent
was obtained at that time. The questionnaire was completed
8 hours following CS by each patient when patients had fully
recovered from general anesthesia. The response rate was
93%. The data were completely collected during the hospital
stay. Pain intensity following CS was significantly influenced
by the following variables: patient education, previous CS,
duration of surgery, type of sutures used, nurses’ attitude
towards pain, method of expressing pain, ambulation post
CS and complications directly related to CS. (Probability
values equal to or less than 0.05 were considered significant.)
Conclusions: A number of factors influence the intensity of
post-operative pain following CS. Most of these factors
cannot be easily controlled and involve patient factors, envir-
onmental issues and health care providers. Education of
patients, nurses and physicians about the concepts of
acute pain management would be an important first step
towards improving pain control following CS. The most ef-
fective way to address the educational issues raised would
be to introduce a team approach to the management of
postoperative pain.
Reference
1 Women’s Health News. CDC December 2007.
Paper No: 1024.0
Effectiveness of intra-operative
ondansetron in reducing post-operative
intrathecal morphine-induced pruritus in
patients undergoing caesarean section
Rufinah Teo, Norsidah Abdul Manap,
Albert Navin Durairatnam and Muhammad Maaya
Department of Anaesthesiology & Intensive Care, Universiti
Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
Introduction: The addition of preservative-free morphine to
intrathecally injected local anaesthetics during spinal anaes-
thesia provides prolonged and effective analgesia following
caesarean section thus enabling patients to be mobilized
earlier. Nevertheless, up to 80% of patients experience prur-
itus due to the intrathecal opioids which is believed to have a
direct irritation effect on neuraxial serotonin type 3 recep-
tors. Ondansetron, a specific 5-hydroxytryptamine-3
(5-HT3) receptor antagonist may have a role in reducing or
abolishing this disturbing symptom of itchiness.
Objectives: This prospective, randomized, double-blinded,
placebo-controlled clinical study evaluated the effectiveness
of 4 mg intravenous ondansetron in reducing the incidence
and severity of 0.15 mg intrathecal morphine-induced prur-
itus in patients undergoing caesarean section.
Methods: Sixty two ASA I or II patients, aged 18 years and
above who met the criteria were randomized into two
ii210
Abstracts presented at WCA 2012
groups. All parturients received an intrathecal injection of
0.5% heavy bupivacaine 1.6 - 2.0 ml, fentanyl 25 mg and
preservative-free morphine 0.15 mg. Immediately after the
delivery of the baby, Group A patients received 4 mg of intra-
venous ondansetron while Group B patients were given 2 mls
of normal saline injection. Pruritus rating (none, mild, moder-
ate or severe) was done at the recovery room, 6 hours, 12
hours and 24 hours postoperatively.
Results: The incidence of pruritus at the recovery room, 6
hours, 12 hours and 24 hours postoperatively for Group A
(ondansetron group) was 64.5%, 72.4%, 41.9% and 29.0%
and Group B (placebo group) 37.8%, 67.7%, 45.2% and
25.8% respectively. Although the incidence of pruritus was
higher in the ondansetron group in the recovery room and
at 6 hours postoperatively, it was not statistically significant.
The incidence of pruritus was highest at 6 hours post-
operatively. None of the patients had severe pruritus that
required rescue medication at all intervals.
Conclusions: This study showed that intra-operative 4 mg
intravenous ondansetron was not effective in reducing the
incidence and severity of 0.15 mg intrathecal
morphine-induced pruritus in patients undergoing caesarean
section.
References
1 Sarvela PJ, Halonen PM, Soikkeli AI, Kainu JP, Korttila KT. 2006.
Ondansetron and tropisetron do not prevent intraspinal morphine-
and fentanyl-induced pruritus in elective caesarean section. Acta
Anaesthesiol Scand 50: 239–244.
2 Yeh HM, Chen LK, Lin CJ, Chan WH, Chen YP, Lin CS, Sun WZ,
Wang MJ, Tsai SK. 2000. Prophylactic intravenous ondansetron
reduces the incidence of intrathecal morphine-induced pruritus
after cesarean delivery. Anesth Analg 91: 172– 175.
3 Charuluxananan S, Kyokong O, Somboonviboon W,
Narasethakamol A, Promlok P. 2003. Nalbuphine versus ondanse-
tron for prevention of intrathecal morphine-induced pruritus
after cesarean delivery. Anesth Analg 96: 1789– 1783.
4 Bonnet MP, Marret E, Josserand J, Mercier FJ. 2008. Effect of
prophylactic 5-HT3 receptor antagonists on pruritus induced by
neuroaxial opioids: A quantitative systemic review. Br J Anaesth
101: 311–319.
5 Ronald BG, Terrence KA, Asraf SH. 2009. Serotonin receptor antago-
nists for the prevention and treatment of pruritus, nausea, and
vomiting in women undergoing cesarean delivery with intrathecal
morphine: A systemic review and meta-analysis. Anesth Analg
109: 174–182.
Paper No: 1044.0
Introducing monitoring of vital signs and
the WHO checklist at Mbarara University
teaching hospital, Uganda: an
observational study
Isabeau Walker 1, Joseph Kiwanuka 2 and
Joseph Ngonzi 3
Abstracts presented at WCA 2012
1
Great Ormond Street Hospital NHS Trust, London, UK, 2 Mbarara
University Teaching Hospital, Mbarara, 3 Mbarara University
Teaching Hospital, Mbarara, Stephen Ttendo Mbarara University
Teaching Hospital, Mbarara, Ivan Wong North West London
Hospitals NHS Trust, London, UK
Introduction: Maternal mortality remains high in sub-
Saharan Africa, and many countries are not on track to
achieve UN Millennium Development Goal 5 by 2015 (1).
Mbarara University Teaching Hospital undertakes approxi-
mately 8000 deliveries per annum (28% caesarean section
rate, MMR 500:100 000 births). Common causes of maternal
death are haemorrhage, sepsis, eclampsia and obstructed
labour. Early recognition of abnormal vital signs and the
use of a surgical checklist have been identified as potential
ways to improve outcomes (2,3).
Objectives: The key objectives of this study were to introduce
routine monitoring of vital signs and the WHO surgical safety
checklist for mothers undergoing caesarean section.
Methods: Ethical approval was obtained. A baseline audit
in August 2010 measured the percentage of mothers
with vital signs recorded pre- and postoperatively. A visit-
ing anaesthetist coordinated training from September
2010 to January 2011. Changes were introduced into prac-
tice using PDSA cycles (plan-do-study-act) to improve
target outcomes. Lack of equipment was identified as a
barrier and 4 mobile monitors were introduced with train-
ing targeted at admission triage. A MEOWS chart and
checklist were formally launched in January 2011. Data
was collected by weekly chart review by trained data
abstractors. Results were plotted as percentages on
weekly run-charts and presented at monthly obstetric
meetings.
Results: Data was obtained for 86 caesarean sections in the
baseline audit and 964 caesarean sections January - June
2011 (83% emergencies). Preoperative and postoperative
blood pressure was recorded in 2/86 (2.3%) and 1/86 (1%)
of patients at baseline. Preoperative blood pressure was
recorded in 100% patients at the end of the study period, a
sustained change in practice. Postoperative observations
improved although the effect was not as marked. The use
of the checklist continued but was not sustained after the
visiting anaesthetist left. Retained surgical swabs were
detected on two occasions as a result of using the checklist.
There were 9 maternal deaths from 1st January to 30th June
(36 deaths in 2010).
Conclusions: We have shown that in resource limited settings
it is possible to improve basic care processes such as routine
blood pressure monitoring through local leadership, training
and introduction of suitable equipment. Regular audits help
change practice and improve patient care. Improvements
in the uptake of the checklist were not sustained, despite
demonstration of utility. Introducing the WHO checklist is a
complex process in any setting and requires local champions
and multidisciplinary team involvement to identify local bar-
riers (4).
BJA
References
1 WHO Making Pregnancy Safer. http://www.afro.who.int/en/
clusters-a-programmes/frh/making-pregnancy-safer.html.
(accessed 3rd September 2012)
2 Bleyer AJ, Vidya S, Russell GB et al. Longitudinal analysis of one
million vital signs in patients in an academic medical center. Re-
suscitation 2011: doi:10.1016/j.resuscitation.2011.06.033
3 Haynes AB, Weiser TG, Berry WR et al. A surgical safety checklist to
reduce morbidity and mortality in a global population. N Engl J
Med 2009 360: 491– 9
4 Kearns RJ, Uppal V, Bonner J et al. The introduction of a surgical
safety checklist in a tertiary referral obstetric centre. BMJ Qual
Saf. 2011 20: 818–22.
Paper No: 1052.0
Anaphylaxis shock probably induced by
Seprafilm (sodium hyaluronate-based
bioresorbable membrane)
Minoru Kawanishi, Junken Koh, Yosiyasu Esaki,
Mahito Kawabata and Masataka Ohishi
Fujita Health University School of Medicine, Banbuntane Hotokukai
Hospital
Introduction: Seprafilm bioresorbable membrane has been
approved for use in any open abdominal or pelvic surgery
to prevent post operative peritoneal adhesions. We experi-
enced anaphylaxis shock probably induced by seprafilm in
the caesarean section.
Case: Patient was 29 year-old female and scheduled for
repeat caesarian section. Her pregnant term was 37months
and she was suffered from severe atopic dermatitis for over
20 years. Brown pigmentation was recognized on her all ex-
tremities and back skin. For the first caesarean section,
seprafilm was not used during operation. Anesthesia was
maintained mainly by spinal anesthesia and propofol was
started for sedation shortly after the baby delivery. Circula-
tory condition was checked every 5minite under spontan-
eous respiration and her circulatory and respiratory
conditions were steadily maintained. But at the time of
skin suturing, her respiratory rate was increased and she
moved her upper extremities. Her pulse rate was increased
to 140/minute and blood pressure was depressed to
50mmHg. Amniotic fluid embolism was first suspected, but
arterial blood analysis showed no respiratory distress data,
PaO2 395mmHg and PaCO2 30mmHg. Blood bleeding into
abdominal space was also suspected, but echo examination
revealed no bleeding around the uterus. Latex catheter was
removed from the bladder for Latex anaphylaxis, but no re-
covery was noticed. Her peripheral blood examination
showed concentrated blood, Hb increased from preoperative
10g/dl to 14.5g/dl. Dramatic circulatory recovery was
obtained by the administration of adrenalin 0.05mg and
Hydrocortizone 500mg.
ii211
BJA
Discussion: Amniotic fluid anaphylaxis was also the possible
cause for this patient. But the time of the occurrence of the
shock was the key point. Shock occurrence time was just
after the application of seprafilm.
Conclusion: Widely and commonly used seprafilm can be the
cause of anaphylaxis shock.
References
1 Beck DE, Cohen Z, Fleshman JW, Kaufman HS, van Goor H,
Wolff BG; Adhesion Study Group Steering Committee; A prospect-
ive, randomized, multicenter, controlled study of the safety of
Seprafilm adhesion barrier in abdominopelvic surgery of the intes-
tine. Dis Colon Rectum. 2003 Oct;46(10): 1310– 9.
2 Becker JM, Dayton MT, Fazio VW, et al. Prevention of postoperative
abdominal adhesions by a sodium hyaluronate-based bioresorb-
able membrane: a prospective, randomized, double– blind multi-
center study. J Am Coll Surg. 1996; 183: 297– 306.
Paper No: 1088.0
Incidence of difficult & failed intubations
during obstetric general anaesthesia in a
tertiary referral centre
Wendy Teoh, Sean Yeoh, Farida Ithnin and
Alex Sia
Dept. of Women’s Anaesthesia, KK Women’s & Children’s Hospital
Singapore
Objective: To determine the incidence of difficult and failed
intubation during general anaesthesia (GA) for cesarean sec-
tions (CS) & pregnancy-related surgery in a tertiary teaching
institution.
Methods: With IRB approval, data on cesarean deliveries &
pregnancy-related surgery performed over 8years from 1
Jan 2004- 31 Dec 2011 were extracted from departmental
audit, critical incident database and clinical notes. We deter-
mined total number of deliveries, cesarean, GA rates and
reviewed charts of all patients with difficult ( ? Grade 3
larynx) or failed intubation (failure to intubate the trachea),
recording parturient demographics, indications for elective/
emergency CS, and for GA, and details of airway manage-
ment (preoperative airway assessment, anaesthetist senior-
ity, adherence to failed intubation protocol, airway adjuncts
used, airway complications).
Results: This study took place in our country’s largest and
busiest tertiary maternity teaching centre which delivers
approx.. 12,000 babies annually. Final results will contain
additional 6mths data until 31 Dec 2011. Preliminary
data(1 jan 2004- 31 July 2011) is presented: 93,401 deliveries
occurred; 26,584 via cesarean section (average CS rate of
30%). Of these, 10.4% were performed under general anes-
thesia. There were 2772 rapid sequence GAs for cesarean de-
liveries and 5065 obstetric GAs (for CS and non-CS)
administered over 7.5years. 14 difficult intubations (grade ?
3 larynx) occurred in the GA -CS series¼1:198 incidence.
ii212
Abstracts presented at WCA 2012
50% cases were emergency CS after hours. There were 6
failed intubations¼1:462 incidence. 6 unanticipated and 7
anticipated difficult airways were identified on preoperative
assessment. 8 of 14 cases were obese (BMI.30). Only 2
patients had severe preeclampsia. All 14 difficult intubations
were handled by anaesthetic consultants or specialist regis-
trars. The failed intubation protocol was followed in all 14
cases, commonest adjuncts used were bougie and McCoy la-
ryngoscope. Five cases were rescued with a LMA Proseal, one
patient was awoken, and spinal performed. There was no
pulmonary aspiration, maternal awareness, or dental
damage. Minor airway complications: 6 transient desatur-
ation, 2 sorethroat, 1 fibreoptic bronchoscopic suction with
post-op ICU monitoring overnight.
Conclusion: We found a difficult intubation incidence of 1:198
and failed intubation 1:462. We attribute this low incidence
of 1:462 to the round-the -clock specialist staffing of our
busy obstetric anaesthesia unit, familiarity with GA with ad-
equate opportunities for training in obstetric intubations
and low maternal morbidity due to the use of the Proseal
LMA, the availability of videolaryngoscopy, and ongoing
multidisciplinary simulation training in high risk obstetric
scenarios and failed intubation drills.
References
1 Lyons G. Anaesthesia 1985; 40: 759–62.
2 Rocke DA, et al. Anesthesiology 1992; 77: 67–73.
3 Hawthorne L, et al. BJA 1996; 76: 680– 4.
4 Tsen LC, et al.IJOA 1998; 7: 147–52.
5 Barnardo PD, et al. Anaesthesia 2000; 55: 690– 4.
6 Rahman K, et al. Anaesthesia 2005; 60: 168– 71.
7 Saravanakumar K. BJA 2005; 94: 690.
8 Kan RK, et al. IJOA 2004; 13: 221–226.
9 McDonnell NJ, et al.. IJOA 2008; 17: 292–7.
10 Djabatey EA, et al. Anaesthesia 2009; 64: 1168– 1171.
Paper No: 1128.0
Influence of enoxaparine on serum
endotoxin concen-tration in puerpera after
abdominal delivery
Aleksey Pyregov
Efim Shifman Oksana Shestakova Tatyana Puchko Igor Baranov
Introduction: Increase of endotoxin concentration was
noticed in patients with severe pre-eclampsia, massive hem-
orrhage, sepsis, small pelvis inflammatory diseases [1-4].
Low-molecular weight heparins (LMWH) are direct anticoa-
gulants, but also they have anti-inflammatory and
endothelial-protective properties [5,6].
Objectives: Determination of serum endotoxin level in puer-
peras with risk fac-tors of thrombotic complications after ab-
dominal delivery.
Abstracts presented at WCA 2012
Day 1 Day 3 Day 5
Study, n¼38 88,4+7,34 133,4+9,76 179,6+15,23
Control, n¼26 87+7,65 135,4+9,91 209,8+19,73
* * p,0,05
Methods: After Ethic Committee approval and obtaining of
informed consent, 72 patients after abdominal delivery
were included in randomized prospective trial. All patients
were randomized into two groups (randomization was per-
formed according to the day of the week). Study group
included 38 women, who obtained daily natrium enoxapar-
ine 40 mg subcutaneously, started 12 hrs after delivery
during 3 days. Control group included 34 patients after ab-
dominal delivery. Inclusion criteria: presence of one or
several risk factors (arterial hypertension, combination of
hereditary thrombophylia gene mutation, varix veins, dia-
betes mellitus, BMI.25, age.35 years). Exclusion criteria:
different inflammation diseases during III trimester, pre-
eclampsia, blood loss during delivery.1000 ml, administra-
tion of LMWH before or 24 hours after delivery, contraindica-
tions for use of LMWH. Groups were comparable by age,
gestational age, indications to delivery, BMI, concomitant
diseases, obstetric history. Duration of cesarean section
was 54,3+4,21 and 53,2+3,75 min, respectively, blood
loss – 894,8+76,78 and 877,9+69,92 ml in study and
control group respectively. Before intervention all patients
obtained prophylactic antibiotic dose. Eight women were
excluded from the study due to demand in LMWH and/or
antibacterial treatment after delivery. Studies of endotoxin
serum level were performed on days 1, 3 and 5 after deli-very
with use of HbtLAL method (quantitative analysis of endo-
toxin level in culture media). Limit of assay sensitivity – 1,
4 pg/ml, range of measurable concentrations - 1 - 1000,0
pg/ml.
Results: Endotoxin levels 3 days after delivery in both groups
were increased in both groups. On 5th post-op day there was
marked increase of endotoxin level in the control group in
comparison with the study group (see table).
Group, n Endotoxin level, EU/ml×10-3
Conclusions: 1. In presence of thrombotic complications risk
factors in patients after abdominal delivery endotoxin levels
are elevating from 3 day after delivery. 2. Use of enoxaparine
after abdominal delivery in patients with thrombotic compli-
cations risk factors led to statistically confident decrease of
serum endotoxine on the 5th day after delivery.
References
1 Lurie S, Feinstein M, Mamet Y. Disseminated intravascular coagulo-
pathy in pregnancy: thorough comprehension of etiology and
management reduces obstetricians’ stress. Arch Gynecol Obstet.
2000 Feb;263(3): 126– 30. Review.
2 Ismail SK, Higgins JR. Hemostasis in pre-eclampsia. Semin Thromb
Hemost. 2011 Mar;37(2): 111– 7. Epub 2011 Mar 2.
BJA
3 Gandhi NS, Mancera RL. Heparin/heparan sulphate-based drugs.
Drug Discov Today. 2010 Dec;15(23-24): 1058–69. Epub 2010 Oct
23. Review. Erratum in: Drug Discov To-day. 2011 Aug;16(15-16):
741
4 Marshall JC. Endotoxin in the pathogenesis of sepsis. Contrib
Nephrol. 2010; 167: 1 –13. Epub 2010 Jun 1. Review.
5 Brewster JA, Orsi NM, Gopichandran N, Ekbote UV, Cadogan E,
Walker JJ. Host in-flammatory response profiling in preeclampsia
using an in vitro whole blood stimulation model. Hypertens Preg-
nancy. 2008; 27(1): 1 –16.
6 Artico M, Riganò R, Buttari B, Profumo E, Ionta B, Bosco S, Rasile M,
Bianchi E, Bruno M, Fumagalli L. Protective role of parnaparin in re-
ducing systemic inflammation and atherosclerotic plaque forma-
tion in ApoE-/- mice. Int J Mol Med. 2011 Apr;27(4): 561–5.
Paper No: 1158.0
Early Epidural Labour Analgesia: Does It
Increase the Chances of Operative
Delivery?
Gundappa Parameswara 1, K Kshama 2,
Hanuman KMurthy 3, KJalaja 4 and ShobhaVenkat 5
1
Senior Consultant in Anaesthesia, Manipal Hospital, Bangalore,
India, 2 Senior Resident in Obstetrics & Gynaecology, Manipal,
3
Consultant in Anaesthesia, Manipal Hospital, 4 Consultant in
Anaesthesia, Manipal Hospital, 5 Consultant in Obstetrics &
Gynaecology, Manipal
Epidural analgesia is commonly employed for labour anal-
gesia. Epidural analgesia has been shown to cause prolong
labour and increase in the incidence of operative delivery.1
Recent observations have not shown any such association.2
Conventionally epidural labour analgesia is administered
during the active phase of labour when cervical dilatation
(CD) is 4cms. Administration of epidural analgesia early in
labour (CD ? 2cms) provides good analgesia but its effect
on the progress of labour is not widely studied. Early labour
analgesia may, increase the duration of labour, and may in-
crease the risk of operative delivery, increase the risk of oxy-
tocin, malposition of foetus and foetal bradycardia due to
maternal hypotension. We compared the efficacy of early
(?2cm cervical dilatation with .50% effacement) versus
late (.2cm cervical dilatation with .50% effacement) epi-
dural analgesia in labouring women and its relation to dur-
ation of labour and mode of delivery.
Methods: 120 term nulliparous primigravidae were adminis-
tered epidural analgesia randomly either early (CD ? 2cms) or
late (CD.2cms). Patients with medical and obstetric contrain-
dications for vaginal delivery were excluded. A bolus of 8 ml of
0.25 % bupivacaine followed by Infusion of 8 ml per hr of 0.125
% bupivacaine with fentanyl (2.5 mg/ml) per hour was given till
delivery. Parameters studied were Intensity of labour Pain, as
assessed by visual analogue scale (VAS), hemodyanmics
(such as blood pressure, pulse rate and oxygen saturation)
degree of sensory level and motor block (Bromage scale),
was assessed every 30min. Further progress of labour, mode
ii213
BJA
of delivery (spontaneous/instrumental/caeserian), APGAR
scores and side-effects of epidural analgesia, if any, were mon-
itored and noted every two hours. If pain relief was inadequate
(VAS.4) 2 ml of additional bolus infusion was given. Data was
analyzed by using ANOVA, Student’s t-test and Chi-square test
or Fischer’s exact test.
Results: Patients in the early epidural group had pain relief
throughout the course of labour where as patients who
received epidural analgesia later in labour experienced pain
for a variable period of time prior to receiving epidural anal-
gesia. There were no significant changes in the hemodynam-
ics between the two groups. The total duration of labour was
not prolonged in early epidural group as compared to the
late epidural group (476.1+46 minutes vs 471.4+62.5
minutes) (p¼0.726). The timing of epidural analgesia did
not affect the mode of delivery (p¼0.428). Incidence of Cae-
sarean section was similar (13/60 in early group vs 14/60 in
late epidural group). Maternal satisfaction was better with
early epidural (76.7% vs 65%) which however was not statis-
tically significant. There was no significant difference
between the APGAR scores at 1 min and 5 min (Scores 8
Vs9). Side effects such as nausea, vomiting, motor block
were minimal and similar between the groups. 1 patient in
early epidural group had motor block and 2 patients in late
epidural group had vomiting.
Conclusion: We could conclude that early epidural placement
provides pain relief throughout the course of labour without
prolonging the duration or increasing the chances of opera-
tive delivery and side effects.
References
1 Am J Obstet Gynecol 1993; 169: 851– 8.
2 NEJM 2005; 352: 655– 65.
Paper No: 1264.0
Postpartum plasma exchange for a severe
pregnancy related microangiopathy
Ana Pires, Maria Pimentel, Clara Rocha,
Clara Carreiro and António Pais Martins
Centro Hospitalar LISBOA Ocidental, LISBOA, Portugal
Introduction: The differential diagnoses of life-threatening
microangiopathic disorders in a postpartum female includes
severe preeclampsia-eclampsia, hemolysis, elevated liver
function tests, low platelets syndrome (HELLP) and throm-
botic thrombocytopenic purpura (TTP). There is a
ii214
Abstracts presented at WCA 2012
considerable overlapping in the clinical and laboratory find-
ings between these conditions, and hence an exact diagnosis
may not always be possible.1 We present the case of a
woman in the postpartum period, showing signs and symp-
toms of a severe microangiopathy, refractory to the support-
ive therapy she underwent, and that the hemolysis was
resolved through plasma exchange therapy (PET).
Clinical Case: A healthy 20 year old, primigravida (25 weeks
gestation) wad admitted to the emergency service for head-
ache and generalized edema. Upon physical examination,
blood pressure was 143/89mmHg, and edema on the ex-
tremities. Analytically: Anemia (9.9 g/dl), thrombocytopenia
(10.000/mm3), elevated liver enzymes (LDH: 3026, Total Bili-
rubin: 1.28mg/dL) and proteinuria + ++ +. For suspicion of
severe HELLP syndrome, 4 pool platelets were administered
and the patient was submitted to a cesarean section,
without complications. The patient was transferred to the
Post Anesthesia Care Unit, but due to worsening of clinical
symptoms had to be transferred to the Surgical Intensive
Care Unit, 24 hours after the cesarean section. At this time
the patient underwent an antihypertensive triple treatment
(Captopril, Indapamide and Nifedipine), Dexamethasone
5 mg every 6 hours, the dose being progressively increased
to 20 mg every 6 hours, fluid and blood component
therapy to correct anemia, low platelets and low urinary
output. Due to the persistence of the severe microangiopa-
thy, with worsening indicators of hemolysis, indication is
given to being PET on the 7th day, revealing improvement
of the analytical parameters from the first session. The
patient held a total of nine sessions. The patient was dis-
charged on the 19th day with: Hb:10.6g/dl, plate-
lets:248000/mm3, total bilirubin:0.20, LDH:678, without
proteinuria.
Discussion: The HELLP syndrome is usually associated with
hypertension and proteinuria and differential diagnoses
includes TTP and differentiation between the two is some-
times difficult, as occurred in the clinical case shown
above. Also, the patient did not respond according to expect-
ancy for 72 hours. In spite of this, we decided to advance
with a PET and the patient responded effectively, with reso-
lution of hemolysis and reversal of organ dysfunction.
Conclusion The distinction between HELLP and TTP may not
always be possible. The PET should be considered in persist-
ent, life-threatening microangiopathy that is refractory to
conservative measures.
Reference
1 Indian J Critical Care Med 2011; 15: 126– 9